Argon laser treatment of von Hippel-Lindau retinal angiomas. I. Clinical and angiographic findings

Vitrectomy-Assisted Excision in the Treatment of Juxtapapillary Retinal Capillary Hemangioma

Juxtapapillary retinal capillary hemangiomas are sight-threatening hamartomas located on or adjacent to the optic nerve. Nonsurgical approaches including laser photocoagulation and cryotherapy have been shown to be effective to reduce exudation in peripheral hemangiomas. However, in juxtapapillary hemangiomas, the functional outcomes are limited due to associated potential damage of the retinal nerve fiber layer. We present an 18-year-old female patient with von Hippel-Lindau (VHL) disease who presented with a juxtapapillary retinal capillary hemangioma associated with a tractional epiretinal membrane (ERM) and secondary macular hole. After vitrectomy-assisted excision of the lesion and inner limiting membrane (ILM) peeling around the macular hole, visual acuity and macular anatomy were recovered at 10 months of follow-up. [Ophthalmic Surg Lasers Imaging Retina 2022;53:570-573.].

Retinal angioma of Von hippel-lindau disease: A case report

Introduction

Von Hippel–Lindau disease (VHL), also known as Von Hippel–Lindau syndrome, is a rare genetic disorder with multisystem involvement. It is characterised by the development of multiple vascularised tumours, particularly cerebellar, retinal and/or visceral. The disease can occur at any age and usually starts with retinal hemangioblastomas.

Case report

We report the case of a 45-year-old female patient with no particular pathological history, who. consulted the ophthalmology department for a change of optical correction.

The funds examination showed an uncomplicated bilateral hemangioma with no other associated signs. Fluorescein angiography confirmed the diagnosis by showing in the left eye a multiple retinal hemangioma visible in the mid-periphery facing the branches of the superior temporal arches. The brain MRI showed a multifocal hemangioblastoma in the posterior cerebral fossa. A renal ultrasound returned normal. The patient had undergone photocoagulation of the retinal lesions to avoid any complications.

Discussion

The German ophthalmologist Eugen von Hippel first described angiomas in the eye. The term Von Hippel–Lindau disease was first used in 1936; however, its use became common only in the 1970s.

Tumours called hemangioblastomas are characteristic of von Hippel-Lindau syndrome. These growths are made of newly formed blood vessels and occurs in the periphery of the retina. Spontaneous progression occurs leading to visual impairment as a result of maculopathy or exudative retinal detachment.

Early recognition and treatment of specific manifestations of VHL can substantially decrease complications and improve quality of life.

Conventional treatment of the retinal hemangioblastomas is laser photocoagulation or cryotherapy depending on the location and size of the lesions. It must be based on the patient's visual symptoms and tumor progression.

Conclusion

Management of patients with VHL disease often requires a multidisciplinary approach. The role of the ophthalmologist is important in the management of this condition since the ocular involvement may be indicative of the disease.

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Von Hippel Lindau disease is a systemic condition whose initial signs are usually ocular.

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The ocular lesion is generally one of the major and revealing manifestations of the disease.

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The risk of progression to blindness is important, making early detection and treatment highly beneficial.

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The role of the ophthalmologist is crucial in the management of this condition.

Transvitreal endoresection of refractory retinal capillary hemangioblastoma after feeder vessel ligation

BACKGROUND AND OBJECTIVE

Retinal capillary hemangioma (RCH) is a developmental vascular tumor occurring sporadically or associated with Von Hippel-Lindau syndrome. Treatment for large solitary RCH is challenging. Laser, cryotherapy, radiotherapy, photodynamic therapy, and en bloc resection for advanced cases have been described in the literature without consensus on standard management.

MATERIALS AND METHODS

A novel technique of 20-gauge transvitreal endoresection of solitary peripheral RCH after ligating the feeder vessels is described.

RESULTS

Tumors were successfully resected after ligating the feeder vessels bimanually in a closed and more controlled ocular environment. Feeder vessel ligation is intended to compensate for the involution time of the caliber of feeder vessels, when postoperative hemorrhage is more likely to occur. Another advantage of ligating the blood vessels is to secure hemostasis without using heavy endocautery. Postoperatively, proliferative vitreoretinopathy remains a concern.

CONCLUSION

Pending a larger randomized trial, performing endoresection in RCH that is large and unresponsive to conventional treatment is an acceptable option.

[Retinal capillary hemangioma and von Hippel-Lindau disease: diagnostic and therapeutic implications]

CLINICAL CASE

Man carrier of the von Hippel-Lindau (VHL) gene, with long-onset loss of vision in left eye. He had a retinal capillary hemangioma (HCR) and diffuse cystic edema in posterior pole. The systemic study revealed bilateral kidney tumors. Laser photocoagulation was performed which produced a subretinal and vitreous hemorrhage that required vitrectomy.

DISCUSSION

Retinal capillary hemangioma (HCR) is the earliest and most frequent manifestation of the von Hippel-Lindau disease. Its detection requires it to be treated early and to rule out other visceral lesions. Laser photocoagulation is the most recommended treatment of small-size HCR. The most frequent complications are vitreous and subretinal haemorrhages.

Kapilläre Hämangiome der Netzhaut beim Von-Hippel-Lindau-Syndrom

Thermal photocoagulation of small peripheral angiomas is the treatment of choice for capillary hemangiomas in patients with von Hippel-Lindau disease. Larger peripheral angiomas are better treated with beta-ray brachytherapy resulting in improved results in terms of local tumor control and the side effects of treatment. Photodynamic treatment is an alternative option in the management of capillary hemangiomas of the retina. Further improvement of the treatment results of photodynamic therapy may be achieved by combination with intravitreal drugs. External beam radiation using either stereotactic techniques or proton radiation must be considered as experimental. The treatment of juxtapapillary angiomas is still a therapeutic dilemma. Vitreoretinal surgery should be confined to advanced stages with tractional detachment or when no other treatment option is available to salvage the eye.

Ocular vascular hamartomas: the relationship with phakomatoses and possible commonalities in pathogenesis

BACKGROUND

Ocular vascular hamartomas may present as isolated lesions or as part of a multisystemic congenital syndrome known as vascular phakomatoses. These syndromes are characterized by ocular, cerebral, and cutaneous lesions. Although each of these lesions manifests distinct characteristics, there may be overlapping characteristics and manifestations attributable to a common pathogenesis.

METHODS

A case series and a literature review are presented illustrating ocular and systemic manifestations associated with vascular hamartomas, with each case representing varying degrees of ocular and systemic expression.

CONCLUSION

Because of the potential ocular morbidity and systemic mortality associated with vascular hamartomas and associated syndromes, the optometrist plays an important role in the management of these patients. In general, understanding the pathogenesis of these diseases may contribute to future treatment and prevention opportunities.

Retinal angiomatosis in von Hippel-Lindau disease: a longitudinal ophthalmologic study

OBJECTIVE

To characterize the clinical course of retinal angiomatosis (RA) in von Hippel-Lindau (VHL) disease.

DESIGN

Retrospective observational case series from a tertiary referral center.

PARTICIPANTS

Fifty-seven consecutive VHL disease patients with RA with a mean follow-up of 7.3 years.

METHODS

A retrospective chart review was performed to characterize the clinical course and functional outcome of RA to substantiate ophthalmic screening recommendations for VHL disease patients.

MAIN OUTCOME MEASURES

Age and visual acuity (VA) at diagnosis, angioma number, size, fundus position and growth behavior, functional outcome, and risk factors for adverse visual outcome (VA < or =20/1000) were evaluated.

RESULTS

The onset of RA was observed to occur between the ages of 5.5 and 62.5 years. Ocular disease was unilateral in 58% of patients at diagnosis; prevalence of bilateral RA as calculated by Kaplan-Meier analysis was 100% at age 56.4 years. Twenty-seven eyes showed an adverse visual outcome, occurring at a mean age of 23.2 years. Risk factors included large angiomas at presentation, first manifestation at a younger age, and symptomatic RA. In most eyes, development of new angiomas was slow and only small angiomas were detected on annual follow-up. Eyes harboring multiple angiomas or RA complicated by retinal detachment were at risk of developing large angiomas after short follow-up intervals. Formation of new angiomas was largely independent of patient age.

CONCLUSIONS

Retinal angiomatosis in VHL disease bears a high risk of severe vision loss at a young age. In uncomplicated RA, annual ocular screening for presymptomatic angiomas is sufficient. Because RA can occur at any age, lifelong ocular screening is recommended in VHL disease gene carriers starting at preschool age.

Photodynamic therapy in the management of juxtapapillary capillary haemangiomas

Capillary haemangiomas occurring on or adjacent to the optic disc pose unique therapeutic problems. Their natural history is highly variable, but has a propensity to lead to the development of progressive exudate with marked deterioration in visual acuity, often culminating in retinal detachment and vitreal haemorrhages. On reviewing the literature, no therapeutic modality has demonstrated an efficacy in treating the lesion and providing an acceptable visual acuity result. A case of a 61-year-old man with a left-sided juxtapapillary capillary haemangioma treated with verteporfin photodynamic therapy is described. The patient's visual acuity improved from 6/36 to 6/12 initially, with an appreciable reduction in exudate and lesion size. Subsequent treatments failed to eradicate the lesion, with visual acuity stabilizing at 6/60. With larger cohorts of patients and variable treatment parameters, the true efficacy of photodynamic therapy to treat these lesions may be determined.

Ophthalmological manifestations in VHL and NF 1: pathological and diagnostic implications

Von Hippel-Lindau disease (VHL) and neurofibromatosis type 1 (NF 1) are hereditary multitumor syndromes that show associated ocular manifestations. Capillary retinal angioma, a benign vascular tumor, is the classical ocular lesion in VHL. It often appears as the first manifestation of the disease and may thus lead to the diagnosis of VHL. Since small angiomas can be treated easily by laser photocoagulation, a regular ocular screening of VHL patients is recommended. Ocular manifestations of NF 1 are more diverse as compared to VHL. Lisch nodules of the iris are an important diagnostic criteria of NF 1 since they can be found in almost every affected patient. Optic glioma can occur both intraorbitally and intracranially. The intraorbital form causes progressive protrusion of the globe and eventually blindness. Extension of the tumor beyond the chiasm worsens the prognosis quoad vitam. The hallmark of NF 1, namely cutaneous neurofibroma can cause visual impairment when affecting the skin of the eyelids. The rare intraorbital pexiform neurofibroma is associated with abnormal development of the orbital bones and infantile glaucoma. It may result in orbital mass effects and therefore may need surgical excision.

Retinal capillary angioma managed with trans-pupillary thermotherapy

Retinal capillary angioma is a tumour-like nodule of the retina and was first described in 1904 by von Hippel. This disease is characterised among the congenital syndromes known as the phakomatoses. It is the only known phakomatosis that does not exhibit skin lesions. A patient with retinal capillary angioma with leakage and haemorrhage is described and the differential diagnosis discussed. In addition, this patient was treated with trans-pupillary thermotherapy and the available therapies are summarised.

Treatment of retinal capillary hemangioma

OBJECTIVE

To report on the methods of treatment and the visual outcome of eyes with retinal capillary hemangioma (RCH).

DESIGN

Retrospective consecutive noncomparative case series.

PARTICIPANTS

Data on 68 patients with RCH were reviewed for the methods of treatment and visual outcome.

METHODS

Statistical analysis using cumulative multinomial logistic regression (generalized estimating equations) was performed to determine significant predictors of visual outcome.

RESULTS

Among 68 patients with RCH with von Hippel-Lindau disease (n = 31) and without von Hippel-Lindau disease (n = 37), we identified 174 RCH in 86 eyes. The overall median age at diagnosis of RCH was 30.8 years (range, 2.8-73.8 years). The RCH was bilateral in 18 cases (26%), and a family history of von Hippel-Lindau disease was positive in 19 cases (28%). Twenty-nine of the tumors (17%) touched the optic disc and were classified as juxtapapillary RCH, and the remaining 145 (83%) were extrapapillary in location. Ninety-nine (58%) RCH were 1.5 mm or smaller in size. The RCH were initially managed by observation (46%), laser photocoagulation (25%), or cryotherapy (23%). Small RCH (< or =1.5 mm in size; 63 of 99; 64%) and those touching the optic disc (14 of 29; 48%) were more likely to be initially observed. Sixty-three (82%) of the 77 RCH that were initially observed remained stable for a median follow-up of 84 months. The remaining 14 progressed and were successfully controlled with laser photocoagulation or cryotherapy. Either laser photocoagulation or cryotherapy was effective as the sole method of treatment in controlling 74% (26 of 35) and 72% (28 of 39) of extrapapillary tumors, with a mean number of 1.2 and 1.1 sessions, respectively. In a multivariate model, the only variables that were significantly related to final vision of </= 20/400 were poor initial vision (P = 0.01, odds ratio [OR], 8.5; 95% confidence interval [CI], 1.7,42) and the presence of retinal/vitreous hemorrhage (P = 0.024, OR, 5.7; 95% CI, 1.3, 25.6).

CONCLUSIONS

RCH can be safely observed initially in selected cases. Laser photocoagulation and cryotherapy are the mainstays of treatment in most cases. Early detection of RCH and treatment before the onset of severe visual loss is recommended.

Benefits and complications of photodynamic therapy of papillary capillary hemangiomas

OBJECTIVE

To evaluate the potential benefit and risks of photodynamic therapy (PDT) in the treatment of papillary capillary hemangioma.

DESIGN

Prospective, noncomparative, interventional case series.

PARTICIPANTS

Five patients with solitary capillary hemangioma on the temporal portion of the optic nerve presenting with exudative decompensation and decrease in visual acuity (VA).

METHODS

All eyes received a standardized PDT treatment with 6 mg/kg body surface area verteporfin and application of 100 J/cm(2) light at 692 nm. One to three PDT courses were performed until resolution of exudation was achieved. A continuous follow-up was provided with documentation 1 week before and at 4 to 6 weeks, 3 months, and 12 months after the last treatment application.

MAIN OUTCOME MEASURES

Functional parameters included best-refracted VA (Early Treatment Diabetic Retinopathy Study), and central scanning laser ophthalmoscope (SLO) scotometry and peripheral (automated perimetry) visual fields; anatomic parameters were presence of retinal edema or serous detachment (ophthalmoscopy) and tumor size (ultrasonography).

RESULTS

Pretreatment VA levels ranged from 20/40 to 20/800; posttreatment levels ranged from 20/64 to 20/2000. Tumor regression with resolution of macular exudate and serous retinal detachment was obtained in all eyes. A decline in VA of 1, 3, and 10 lines, respectively, was documented in three patients. Complications included transient decompensation of vascular permeability, occlusion of retinal vessels, and ischemia of the optic nerve.

CONCLUSIONS

PDT is successful in reducing tumor size and exudative activity. Vaso-occlusive effects at the level of the retina and optic nerve compromise the functional benefit. Parameters proven safe in choroidal neovascularization may be inappropriate in retinal capillary lesions of the optic nerve.

von Hippel-Lindau disease

In recent years advances have been made in the clinical and genetic aspects of von Hippel-Lindau disease (VHL). Retinal capillary hemangioma is the most common manifestation of VHL disease and, therefore, ophthalmologists are frequently involved in the care of patients with this disease. The incidence of VHL disease is approximately 1 in 40,000 live births. It is estimated that there are approximately 7000 patients with VHL disease in the USA. The inheritance of VHL disease is autosomal dominant with high penetrance. Depending on the clinical circumstances, retinal capillary hemangioma may be managed by observation, laser photocoagulation, cryotherapy, and plaque radiotherapy. Typical extraocular lesions associated with VHL disease are central nervous system hemangioma, renal cyst, renal carcinoma, pancreatic cysts and adenoma, pancreatic islet cell tumors, pheochromocytoma, endolymphatic sac tumor of the inner ear, and cystadenoma of the epididymis and the broad ligament. The life expectancy of affected individuals may be improved by early detection and treatment of varied manifestations with the use of surveillance protocols. Identification of the VHL gene on chromosome 3p25-26 has now made it possible for suspected individuals to undergo genetic testing with a high degree of accuracy. We review herein the ophthalmic manifestations and treatment of retinal capillary hemangioma and systemic findings of the VHL disease.

Therapeutic options for capillary papillary hemangiomas

PURPOSE

To describe the results and therapeutic complications of treatment of papillary capillary hemangiomas over the last 13 years.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Five cases of unilateral capillary papillary hemangiomas were reviewed. Three patients had von Hippel-Lindau disease, and two had no associated familial or systemic disease.

METHODS

Two patients were treated with argon green laser, one patient received argon green and diode photocoagulation, and two patients underwent argon green photocoagulation and diode transpupillary thermotherapy (TTT); two eyes also underwent vitreoretinal surgery. Follow-up ranged from 1 to 13 years.

MAIN OUTCOME MEASURES

The presence of exudative retinal detachment associated with the activity of the hemangioma and the visual acuity were the two main parameters.

RESULTS

Prompt argon green laser treatment was the most effective therapy; -II was ineffective. Vitreoretinal surgery, transscleral drainage, and argon endolaser photocoagulation in one case resolved bullous retinal detachment secondary to tumor exudation. Pretreatment visual acuity (VA) levels ranged from 20/25 to counting fingers; posttreatment VA levels ranged from 20/25 to light perception.

CONCLUSIONS

If left untreated, papillary hemangiomas may evolve to exudative retinal detachment and marked VA decreases. Although we have not established an ideal therapy, we recommend appropriate treatment on diagnosis. Close follow-up and multiple treatments with argon laser are likely the best therapeutic course.

Ruthenium-106 brachytherapy for peripheral retinal capillary hemangioma

OBJECTIVE

This study aimed to evaluate the efficacy and safety of ruthenium-106 brachytherapy of large peripheral retinal capillary hemangiomas.

DESIGN

A retrospective case series.

PARTICIPANTS

In 25 eyes of 24 patients, peripheral capillary retinal hemangiomas were treated.

INTERVENTION

Brachytherapy using 106-ruthenium/106-rhodium plaques was performed.

MAIN OUTCOME MEASURES

Eyes were reviewed for hemangioma regression after brachytherapy, occurrence of retinal detachment, requirement of additional vitreoretinal surgery, final visual outcome, and final retinal status.

RESULTS

Preoperative mean visual acuity of all eyes treated was 20/60, mean hemangioma diameter was 3.8 mm, corresponding to approximately 2 disc diameters. In 14 eyes, the retina was attached before surgery, 8 eyes showed an exudative detachment, and 3 eyes showed a traction detachment. Fifteen patients had definite von Hippel-Lindau syndrome. Twenty-three of 25 hemangiomas could be destroyed by single brachytherapy. In 16 eyes, a favorable outcome could be achieved. In nine eyes, outcome was unfavorable, characterized by a severe drop in visual acuity, a persisting exudative retinal detachment, or a recurrent traction detachment. In one eye requiring repeated brachytherapy, irradiation retinopathy occurred. Hemangiomas up to a size of approximately 5.0 mm without preoperative exudative detachment could be treated safely by brachytherapy, whereas a larger hemangioma size or a pre-existing exudative retinal detachment predisposed to an unfavorable outcome.

CONCLUSION

Solitary peripheral retinal hemangioma can be ablated effectively by ruthenium-106 brachytherapy. A favorable outcome can be expected if the hemangioma diameter is 5.0 mm or smaller and if there is no preoperative exudative retinal detachment.

Clinical features and molecular genetics of Von Hippel-Lindau disease

Although familial cancer syndromes are rare, a knowledge of these disorders is relevant to both clinicians and basic scientists. This is exemplified by Von Hippel-Lindau (VHL) disease which is caused by germline mutations in the VHL tumour suppressor gene. This multisystem disorder provides a complex clinical problem for ophthalmologists and other specialists. In addition, recent advances in the molecular genetics of this disorder are providing novel insights into the molecular mechanisms of tumourigenesis in VHL disease and in more common nonfamilial neoplasms such as clear cell renal carcinoma and central nervous system haemangioblastoma. In this review, we describe the clinical manifestations (with particular reference to the ocular complications) and the molecular genetics of VHL disease.

Von Hippel-Lindau disease associated with an invasive choroid plexus tumour presenting as a middle ear mass

Cerebellar haemangioblastomata and angiomata of the retina are the most common vascular tumours seen in von Hippel-Lindau disease. A definite association between this condition and choroid plexus tumour has not been described previously and its presentation as a middle ear mass is unique.

Laser treatment of retinal angiomatosis

We have treated 26 retinal angiomas of less than 4.5 mm in size in 15 eyes using repeated applications of contiguous argon blue green laser burns. All except one of the angiomas regressed without a massive exudative response of treatment. Haemorrhage occurred in two cases but only affected the visual outcome in one eye. Traction retinal detachment persisted in 50% of the large angiomas, despite regression of the tumour.

Multicentric hemangioblastomas in the cerebellum

An 18-year-old female patient who had been diagnosed as having von Hippel-Lindau disease was admitted to our hospital with signs of increased intracranial pressure. Computed tomographic examination and vertebral angiography revealed the presence of five multicentric cerebellar nodules, of which three had newly occurred in the opposite hemisphere, probably sometime during the 3 years before admission. This case gives us some insights into the biological multipotentiality of cerebellar hemangioblastoma. We stress that close observation is absolutely necessary for this unique group of tumors, even after total excision.

Ocular manifestations of the neurocutaneous syndromes

Ocular involvement occurs frequently in the disorders known as neurocutaneous syndromes or phakomatoses. Recognition of characteristic eye lesions in the context of related skin and systemic abnormalities may be crucial to making the diagnosis of a neurocutaneous syndrome. Ocular disease in these conditions may be the cause of serious morbidity, leading to blindness or disfigurement, but successful treatment is often possible. All clinicians involved in the care of patients with neurocutaneous syndromes should have some familiarity with their ophthalmologic aspects. This review deals with ocular manifestations of neurofibromatosis, tuberous sclerosis, Sturge-Weber syndrome, von Hippel-Lindau disease, ataxia telangiectasia, and Bloch-Sulzberger syndrome. Clinical signs and symptoms, differential diagnosis, and natural history are considered in detail, with brief discussion of pathophysiology and management. No specialized knowledge of eye disease in general is presumed.

von Hippel-Lindau disease: a familial, often lethal, multi-system phakomatosis

A review of 36 cases of von Hippel-Lindau disease underscores the important role of the ophthalmologist in evaluating this phakomatosis. Retinal angiomatosis occurred in almost two-thirds of those affected, was usually diagnosed before other target organs, and frequently led to decreased visual acuity. Common non-ophthalmic manifestations included cerebellar (69%), medullary (11%) and spinal (8%) hemangioblastoma, renal cell carcinoma (22%), and polycythemia (17%). Pheochromocytoma was a les common association. The most common causes of death were cerebellar hemangioblastoma and renal cell carcinoma. For the surveillance of suspected von Hippel-Lindau victims, a detailed family history and retinal examination is recommended. Essential laboratory tests include a complete blood count and computed tomography of the head, upper cervical region, and abdomen. Periodic pre-symptomatic screening is imperative for follow-up investigation of affected individuals to determine possible additional occult manifestations and of non-affected family members at risk to von Hippel-Lindau disease.

Treatment of large von Hippel tumors by eye wall resection

Two large angiomas (greater than 3 disc diameters) in two patients with von Hippel disease were removed successfully by eye wall resection. The resection of angioma in the first case resulted in improved visual acuity from counting fingers to 20/140, decreased exudates, and cessation of preoperative diffuse retinal capillary leakage observed by fluorescein angiography. The resection in the second case with pre-existing local tractional retinal detachment was tolerated well. The patient retained her preoperative visual acuity of 20/25, and retinal traction was released. Although a complicated surgical procedure, resection of large angiomas offers a good alternative therapy to tumors resistant to cryocoagulation or photocoagulation.

Bilateral peripapillary exophytic retinal hemangioblastomas

A 14-year-old Iranian girl was referred for evaluation of bilateral elevation of the peripapillary retina. Fluorescein angiography was consistent with bilateral peripapillary exophytic retinal hemangioblastomas as seen in angiomatosis retinae (von Hippel's disease). Argon laser photocoagulation of the more severely affected left eye was performed with minimal effect upon the tumor.

Classification and management of hereditary retinal angiomas

Two distinct types of retinal angiomas are currently recognized. Capillary hemangiomas occur most characteristically as part of the von Hippel-Lindau syndrome. The retinal capillary hemangiomas typically appear as globular red-orange tumors with dilated and tortuous afferent arterioles and efferent venules. Cavernous hemangiomas typically appear as grape-like clusters of dilated vascular sacs without pronounced alteration in the adjacent arterioles and venules. The spectrum of clinical features of these two types of hemangiomatosis and current approaches to management of patients with these disorders is reviewed.

Laser applications in medicine and biology: a bibliography

This bibliography covers the period from 1963 through 1974; 916 references are classified under 23 subject headings. The references are arranged chronologically.