Peripapillary Versus Macular Combined Hamartoma of the Retina and Retinal Pigment Epithelium: Imaging Characteristics

Seven-year follow-up of a pediatric patient with combined hamartoma of retina and retinal pigment epithelium complicating with preretinal neovascularization and vitreous hemorrhage treated with intravitreal injections of bevacizumab

We report a case of successful management of intravitreal injections of anti-vascular endothelial growth factor antibody bevacizumab in two unusual complications, preretinal neovascularization and vitreous hemorrhage, secondary to a combined hamartoma of the retina and retinal pigment epithelium (CHRRPE). A male pediatric patient suffered from decreased vision in the right eye at 5-year-old. His ophthalmologic examination revealed a CHRRPE involving the superior area of the optic disc and macula in the right eye. The patient's family history and neurological examinations of tuberous sclerosis were absent. While no lesion growth was observed over time, preretinal vascularization and recurrent nonclearing hemorrhage occurred 2 years after the initial presentation. The patient was successfully managed with two intravitreal injections of bevacizumab. No recurrences of vitreous hemorrhage were observed at a 7-year post-treatment follow-up. Intravitreal injections of bevacizumab were safe and effective in the management of uncommon complications of preretinal neovascularization and vitreous hemorrhage of CHRRPE in a pediatric patient in long-term follow-up.

Description and surgical management of epiretinal membrane due to combined hamartoma of the retina and retinal pigment epithelium

Purpose

To outline the characteristics of Combined Hamartoma of the Retina and Retinal Pigmentation Epithelium (CHRRPE) and provide a comprehensive overview of surgical management of epiretinal membrane (ERM) caused by CHRRPE.

Main text

CHRRPE is a rare ocular tumor. It clinically mimics other diseases such as retinoblastoma and choroidal melanoma. The present study reviewed the multimodal imaging of CHRRPE, highlighted the multimodal imaging modalities which are useful for revealing the unique features of CHRRPE and hence allowing physicians to confirm the diagnosis.Although most of CHRRPEs are benign harmatoma, progressive visual loss may occur because of the traction of the tumor and other complications. It is treated through surgical removal of the ERM caused by CHRRPE to free retina from the traction. Currently, there is no consensus on the surgical management of CHRRPE. Therefore, the current review was designed to explore the surgical management of ERM caused by CHRRPE and hence provide updated data on this subject.

Conclusions

Multimodal imaging technologies, especially optical coherence tomography (OCT), significantly contributes to the diagnosis of CHRRPE and visual prognosis. Surgical management of CHRRPE through removal of ERM is beneficial in patients with worsening VA which is secondary to ERM which is associated with CHRRPE. However, the strategy is limited to patients with long-standing poor vision. However, earlier surgical therapy and subsequent postoperative amblyopia therapy can be explored for children of amblyogenic age.

COMBINED HAMARTOMA OF THE RETINA AND RETINAL PIGMENT EPITHELIUM AT PEDIATRIC AGE: Surgical Versus Conservative Approach

PURPOSE

To report outcomes of pediatric patients with combined hamartoma of the retina and the retina pigment epithelium followed up conservatively or after pars plana vitrectomy.

METHODS

This retrospective multicenter study included 62 eyes of 59 pediatric patients with combined hamartoma of the retina and the retina pigment epithelium from 13 different international centers with an average age of 7.7 ± 4.7 (0.3-17) years at the time of the diagnosis and having undergone pars plana vitrectomy or followed conservatively. At baseline and each visit, visual acuity values, optical coherence tomography for features and central foveal thickness, and tumor location were noted. Lesions were called as Zone 1, if it involves the macular and peripapillary areas, and the others were called as Zone 2 lesions.

RESULTS

Twenty-one eyes of 20 patients in the intervention group and 41 eyes of 39 patients in the conservative group were followed for a mean of 36.2 ± 40.4 (6-182) months. Best-corrected visual acuity improved in 11 (68.8%) of 16 eyes in the intervention group and 4 (12.9%) of 31 eyes in the conservative group ( P < 0.001). The mean central foveal thickness decreased from 602.0 ± 164.9 µ m to 451.2 ± 184.3 µ m in the intervention group, while it increased from 709.5 ± 344.2 µ m to 791.0 ± 452.1 µ m in Zone 1 eyes of the conservative group. Posterior location of tumor, irregular configuration of the foveal contour and ellipsoid Zone defect in optical coherence tomography, subretinal exudate and prominent vascular tortuosity were associated with poor visual acuity.

CONCLUSION

Vitreoretinal surgery is safe and effective in improving vision and reducing retinal distortion in Zone 1 combined hamartoma of the retina and the retina pigment epithelium in children.

Changing trends in pseudoretinoblastoma diagnoses: A 10 year review from the United Kingdom

AIM

To study the different types and frequency of pseudoretinoblastoma (pseudoRB) lesions who present to a retinoblastoma centre due to concern that the condition may be retinoblastoma.

METHODS

A retrospective chart review of 341 patients presenting sporadically to the Royal London Hospital from January 2009 to December 2018.

RESULTS

220 patients (65%) were confirmed to have retinoblastoma, while 121 (35%) had pseudoRB. There were 23 differential diagnoses in total. The top 3 differential diagnoses were Coats' disease (34%), Persistent Foetal Vasculature (PFV) (17%) and Combined Hamartoma of Retina and Retinal Pigment Epithelium (CHR-RPE) (13%). PseudoRBs differed with age at presentation. Under the age of 1 (n = 42), the most likely pseudoRB conditions were PFV (36%), Coats' disease (17%) and CHR-RPE (12%). These conditions were also the most common simulating conditions between the ages of 1 and 2 (n = 21), but Coats' disease was the most common in this age group (52%), followed by CHR-RPE (19%) and PFV (14%). Between the ages of 2 and 5 (n = 32), Coats' disease remained the most common (44%) pseudoRB lesion followed by CHR-RPE (13%), or PFV, Retinal Astrocytic Hamartoma (RAH), familial exudative vitreoretinopathy (FEVR) (all 6.3%). Over the age of 5 (n = 26), pseudoRBs were most likely to be Coats' disease (35%), RAH (12%), Uveitis, CHR-RPE, FEVR (all 7.7%).

CONCLUSION

35% of suspected retinoblastoma cases are pseudoRB conditions. Overall, Coats' disease is the most common pseudoRB condition, followed by PFV. Hamartomas (CHR-RPE & RAH) are more prevalent in this cohort, reflecting improvements in diagnostic accuracy from referring ophthalmologists.

Secondary Choroidal Neovascularization in Combined Hamartoma of the Retina and Retinal Pigment Epithelium

Purpose:

To report a 4-year-old boy with a large, macula-involving combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) lesion with an associated choroidal neovascular membrane involving the fovea, characterized with multimodal imaging.

Methods:

Case report.

Results:

Given the low likelihood of visual improvement with intervention, observation was recommended and the CHRRPE remained stable on follow-up 4 months after presentation.

Conclusion:

CHRRPE is a rare congenital retinal lesion that is variably pigmented. Awareness of rare complications, such as CNVM, as seen in this pediatric case is paramount.

Common clinical features of unilateral retinal pigment epithelium dysgenesis and combined hamartoma of the retina and retinal pigment epithelium

Background

Herein, we report two cases of unilateral retinal pigment epithelium dysgenesis (URPED) in Chinese patients and explore the relationship between URPED and combined hamartoma of the retina and retinal pigment epithelium (CHRRPE).

Case presentation

The lesion margins in the two cases showed pathognomonic clinical features of URPED, namely, a scalloped reticular margin in hyperplastic retinal pigment epithelium and mild fibrosis. The hypoautofluorescence observed by fundus autofluorescence was inverted compared with that observed by fundus fluorescence angiography. A large amount of fibroglial proliferation and disorganization of the retina involving the whole layer, which are also found in peripapillary CHRRPE, were found in the lesions.

Conclusions

URPED appears to share some clinical features with CHRRPE, and the relationship between URPED and CHRRPE needs further study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02244-x.

Surgery for Combined Hamartoma of the Retina and Retinal Pigment Epithelium

There is no consensus on whether and when surgical treatment is indicated for combined hamartoma of the retina and retinal pigment epithelium (CHRRPE). We aim to discuss the benefits of surgical intervention and techniques that may improve the outcome. A 24-year-old man experienced progressive visual loss for 6 months in his left eye due to CHRRPE. At presentation, visual acuity was 1.3 LogMAR and fundoscopy revealed extensive tractional pre- and epiretinal membranes, subretinal exudation, and a vasoproliferative tumor in the inferior periphery. A complete vitrectomy was performed, while paying special attention to vitreous shaving at the vitreous base and removal of vitreoschisis-induced vitreous cortex remnants (VCR) from the retinal surface posterior to the vitreous base. Tractional membranes and internal limiting membrane were peeled, and the vasoproliferative tumor was excised. Silicone oil tamponade was removed 11 weeks after surgery. No intra- or postoperative complications occurred. Visual acuity improved to 0.8 LogMAR and remained stable for 48-month follow-up. Vitreoretinal surgery can prevent complications that occur with CHRRPE. In addition, visual function may improve even if the initial visual acuity is low. Timely and complete vitrectomy with extensive membranectomy and detection and removal of VCR is recommended to avoid complications in challenging CHRRPE.

Peripheral combined hamartoma of the retina and retinal pigment epithelium with remote peripapillary choroidal neovascular membrane

Purpose

To describe the first reported case of combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) associated with a remote choroidal neovascular membrane (CNVM).

Observations

A 19-month-old girl with a normal prenatal and infantile history presented with esotropia of the left eye. Fundus examination demonstrated a large, elevated, charcoal-colored lesion in the nasal equatorial retina. There was dragging of the nasal retinal vessels and a retinal fold, presumed to have resulted from nasal traction from the lesion. There was also subretinal hemorrhage in the peripapillary macula. Multimodal imaging demonstrated a peripapillary choroidal neovascular membrane (CNVM) underlying the retinal fold. There was no leakage within the tumor or secondary retinal neovascularization. Examination of the fellow eye was unremarkable. The patient was diagnosed with peripheral CHRRPE with associated peripapillary CNVM. She was treated with serial intravitreal bevacizumab to the affected eye which resulted in a reduction in leakage from the CNVM and resolution of the subretinal hemorrhage. The CHRRPE remained stable on follow-up.

Conclusions

Peripheral CHRRPE can rarely be associated with a remote CNVM.

Staged approach to treatment of combined hamartoma of the retina and retinal pigment epithelium

Combined hamartoma of the retina and retinal pigment epithelium (RPE) is a rare congenital benign lesion. It is most often detected in young adults and adolescents. The disorder is mostly asymptomatic, however, in 24% of patients the loss of visual function results from complications, such as epiretinal fibrosis associated with tractional distortion of the fovea, hemophthalmos, choroidal neovascularization, exudative retinal detachment, macular edema, and combined tractional/rhegmatogenous retinal detachment. Currently, there is no consensus on the combined hamartoma complications management. The reported clinical case demonstrates the feasibility of staged approach to treatment of combined hamartoma of the retina and RPE complicated by epiretinal fibrosis and partial hemophthalmos using the advanced diagnosis (optical coherence tomography) and treatment methods.