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Wang L, Tang T, Wang J, Lin T, Li Y, Song X. Could a low-dose definitive radiation therapy be the optimal treatment for choroidal hemangioma? Radiother Oncol 2024; 196:110282. [PMID: 38641260 DOI: 10.1016/j.radonc.2024.110282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/21/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024]
Abstract
PURPOSE To determine the efficacy of low-dose intensity-modulated radiation therapy (IMRT)/volumetric intensity-modulated arc therapy (VMAT) in the treatment of symptomatic choroidal hemangioma (CH). MATERIALS AND METHODS Fifty-three consecutive patients with CH were retrospectively reviewed. All the patients underwent IMRT/VMAT as a unique treatment. Resolution of subretinal fluid (SRF), improvement of best-corrected visual acuity (BCVA), and reduction in tumor thickness were compared before and after radiotherapy. RESULTS After definitive radiotherapy, 100 % of SRF and 76.7 % of exudative retinal detachment were resolved. 56.6 % of BCVA improvement in more than two lines was observed. The mean best-corrected visual acuity was 20/280 (range, 20/1200-20/40) at diagnosis and 20/100 (range, 20/1200-20/20) after treatment. The mean tumor thickness decreased significantly from 3.8 mm initially to 1.2 mm after treatment (p < 0.01). 66.0 % of patients were delivered with 21.6 Gy (range, 21.6-42 Gy), 84.9 % of fractional dose was 1.8 Gy (range, 1.8-2 Gy). No radiation-induced keratitis, retinopathy, or optic neuropathy were observed. Initial vision (p = 0.042), duration time of vision (p = 0.004), and tumor thickness (p = 0.049) were prognostic factors for vision recovery. CONCLUSION Low-dose IMRT/VMAT could effectively induce involution of the CH, with reduction of subretinal fluid and relief of damage to the neurosensory retina, which is an effective treatment mode for CH.
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Affiliation(s)
- Li Wang
- Department of Radiation Oncology, Eye & ENT Hospital, Fudan University, 83 Fenyang Road, Shanghai 200031, China
| | - Tianci Tang
- Department of Radiation Oncology, Eye & ENT Hospital, Fudan University, 83 Fenyang Road, Shanghai 200031, China
| | - Jie Wang
- Department of Radiation Oncology, Eye & ENT Hospital, Fudan University, 83 Fenyang Road, Shanghai 200031, China
| | - Tong Lin
- Department of Ophthalmology, Eye & ENT Hospital, Fudan University, 83 Fenyang Road, Shanghai 200031, China
| | - Yi Li
- Department of Oncology, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming 650031, China.
| | - Xinmao Song
- Department of Radiation Oncology, Eye & ENT Hospital, Fudan University, 83 Fenyang Road, Shanghai 200031, China.
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Lupidi M, Centini C, Castellucci G, Nicolai M, Lassandro N, Cagini C, Rizzo C, Chhablani J, Mariotti C. New insights on circumscribed choroidal hemangioma: "bench to bedside". Graefes Arch Clin Exp Ophthalmol 2024; 262:1093-1110. [PMID: 37505277 PMCID: PMC10995022 DOI: 10.1007/s00417-023-06179-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/12/2023] [Accepted: 07/16/2023] [Indexed: 07/29/2023] Open
Abstract
Circumscribed choroidal hemangioma is a rare vascular hamartoma of the choroid, presenting as a red-orange mass at the posterior pole on fundoscopic examination. Despite its benign origin, associated complications such as subretinal fluid, serous retinal detachment, retinoschisis and neovascular glaucoma may lead to serious visual impairment in more than half patients. Because of its similarity to amelanotic choroidal melanoma and choroidal metastasis, differential diagnosis is still challenging for specialists. Multimodal imaging such as ultrasonography, fluorescein angiography, indocyanine green angiography, optical coherence tomography, and optical coherence tomography angiography guides the clinician to the correct diagnosis and the proper follow-up. Treatment is indicated in symptomatic cases in order to resolve exudation and improve visual acuity. Treatment options include photocoagulation, transpupillary thermotherapy, radiation therapy, photodynamic therapy and anti-vascular endothelial growth factor therapy. Currently, photodynamic therapy is the treatment of choice due to its effectiveness and safety. The purpose of this review is to describe the latest knowledge in the etiopathogenesis of the circumscribed choroidal hemangioma, the most recent multimodal imaging findings, and the available treatment options.
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Affiliation(s)
- Marco Lupidi
- Eye Clinic, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy.
- Fondazione Per La Macula Onlus, Dipartimento Di Neuroscienze, Riabilitazione, OftalmologiaGenetica e Scienze Materno-Infantili (DINOGMI), University Eye Clinic, Genoa, Italy.
| | - Chiara Centini
- Eye Clinic, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Greta Castellucci
- Department of Medicine and Surgery, University of Perugia, S. Maria Della Misericordia Hospital, Perugia, Italy
| | - Michele Nicolai
- Eye Clinic, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Nicola Lassandro
- Eye Clinic, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Carlo Cagini
- Department of Medicine and Surgery, University of Perugia, S. Maria Della Misericordia Hospital, Perugia, Italy
| | - Clara Rizzo
- Ophthalmic Unit, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Jay Chhablani
- Department of Ophthalmology, UPMC Eye Center, University of Pittsburgh, Pittsburgh, USA
| | - Cesare Mariotti
- Eye Clinic, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
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Takizawa D, Okumura T, Mizumoto M, Nakai K, Sakurai H. A Case of Circumscribed Choroidal Hemangioma Treated With Proton Beam Therapy and Followed Up for 15 Years. Cureus 2024; 16:e52389. [PMID: 38361666 PMCID: PMC10868711 DOI: 10.7759/cureus.52389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/17/2024] Open
Abstract
Circumscribed choroidal hemangiomas are rare and benign tumors but often have a progressive course and are complicated by retinal detachment and glaucoma. The effectiveness of external radiation for large tumors that are difficult to treat with photodynamic therapy was recently reported; however, few studies have conducted long-term follow-ups. We encountered a case of localized choroidal hemangioma that was treated with proton beam therapy and followed up for 15 years. A 37-year-old man was diagnosed with a 10 × 4 mm circumscribed choroidal hemangioma involving the macular area with retinal detachment. Proton beam therapy was performed at 26.4 Gy relative biological effectiveness (RBE) in 8 fractions. The choroidal hemangioma gradually shrank over three years, and the retinal detachment also improved. A cataract developed on the affected side 11 years after irradiation, and eye coordination issues developed 15 years after irradiation. Glaucoma was not observed during the follow-up period; however, visual acuity did not recover, and the patient developed light perception. Although vision was not preserved, proton beam therapy effectively shrank the tumor and maintained quality of life.
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Affiliation(s)
| | - Toshiyuki Okumura
- Radiation Oncology, Ibaraki Prefectural Central Hospital, Kasama, JPN
- Radiation Oncology, University of Tsukuba, Tsukuba, JPN
| | | | - Kei Nakai
- Radiation Oncology, University of Tsukuba, Tsukuba, JPN
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Alshehri WM, AlAhmadi BO, Alhumaid F, Khoshhal MS, Khawaji ZY, AlHabuobi H, Alosaimi AM, Alkhathami A, Alorainy J. Safety and Efficacy of Photodynamic Therapy in the Treatment of Circumscribed Choroidal Hemangioma: A Systematic Review. Cureus 2023; 15:e50461. [PMID: 38222120 PMCID: PMC10786325 DOI: 10.7759/cureus.50461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/16/2024] Open
Abstract
Circumscribed choroidal hemangioma (CCH) is a sort of non-malignant hamartomatous tumor that occurs in the choroidal layer of the eye. It is a rare condition that affects people between their second and fourth decades of life, leading to significant deterioration of vision. One of the most catastrophic consequences of CCH is exudative retinal detachment (ERD), which has a severe impact on vision. This review aims to comprehensively assess the safety and efficacy of photodynamic therapy (PDT) using verteporfin as a therapeutic approach. Using the eligibility criteria, we analyzed the findings of 18 published articles from PubMed, Web of Science, Scopus, and Cochrane. The standard PDT protocol was used in all included studies, except two (one used half-dose, the other one used the double-dose) with an average of 1-2 sessions. PDT induced substantial tumor regression, with a mean thickness range from 0 to 2.3 mm. However, this contrasted with a previous study that reported a thickness of 3.46 mm as an indication of PDT failure. The mean tumor diameter varied from 4.8 mm to total tumor flattening. A suboptimal effect with a mean diameter ranging from 6mm to 8mm was found in two clinical studies. Significant improvement in vision was observed during the last follow-up, ranging from a normalization of Best Corrected Visual Acuity (BCVA) 20/20 to 20/80; counting finger vision persisted in two patients even after treatment. PDT successfully achieved complete subretinal fluid (SRF) resolution in 14 studies and resolved ERD in nine articles. Most studies did not report serious adverse events, but some reported macular atrophy, microcystic degeneration of the retina, transient visual disturbances, Retinal pigmented epithelium (RPE) metaplasia, and cystic degeneration of the retina. This systemic review demonstrated PDT's effectiveness and safety as a first-line management modality for CCH. Photodynamic therapy efficiently induced tumor regression, resulting in a notable reduction in both tumor diameter and thickness, with optimal efficacy to improve vision and resolution of the consequences of CCH, such as SRF and ERD.
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Affiliation(s)
| | - Badr O AlAhmadi
- Ophthalmology, Prince Mohammed bin Abdulaziz Hospital, Madinah, SAU
| | - Fatima Alhumaid
- Ophthalmology, Imam Abdulrahman Bin Faisal University, Alkhobar, SAU
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Kumar A, Shankar S, Singh A, Mishra S, Kumar P, Arora A. Photodynamic therapy in the treatment of circumscribed choroidal hemangioma: Current perspectives. Photodiagnosis Photodyn Ther 2022; 39:103000. [DOI: 10.1016/j.pdpdt.2022.103000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/29/2022] [Accepted: 07/01/2022] [Indexed: 11/16/2022]
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Kumar A, Kumar P, Mishra SK, Jhanawar M, Gupta A, Sathagopam S. Half-fluence photodynamic therapy in peripapillary circumscribed choroidal haemangiomas. Int Ophthalmol 2022; 42:1605-1612. [PMID: 35088358 DOI: 10.1007/s10792-021-02154-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of half-fluence photodynamic therapy (PDT) as treatment for symptomatic peripapillary circumscribed choroidal haemangiomas (CCHs). METHODS In this prospective, interventional case series; 11 patients with symptomatic peripapillary CCHs presenting to a single centre were treated with half-fluence PDT using verteporfin 6 mg/m2 with fluence of 25 mJ/cm2 (standard is 50 mJ/cm2) and other standard settings. Patients were evaluated at baseline, four weeks, twelve weeks and twenty-four weeks post-PDT treatment with best corrected visual acuity (BCVA), ultrasonography, spectral domain optical coherence tomography (SD-OCT), visual evoked potential and angiographic studies. RESULTS Eleven patients with peripapillary CCHs received half-fluence PDT. The BCVA significantly improved to 0.558 ± 0.118 at four weeks post-treatment (P = 0.014), to 0.494 ± 0.114 at twelve weeks (P = 0.006) and 0.441 ± 0.125 at twenty-four weeks (P = 0.007) from baseline levels of 1.017 ± 0.075 on log MAR scales. Similar improvement was observed in central macular thickness (CMT) of 78.50 ± 13.73 μm (P = 0.001) at four weeks; 114.70 ± 27.73 μm (P = 0.003) at twelve weeks and 174.60 ± 23.13 μm (P = 0.001) at twenty-four weeks post-treatment. A single session of re-treatment was required in 18% (n = 2) of patients which also showed complete resolution at last follow-up. No complications were observed without any significant change in retinal nerve fibre layer (RNFL) thickness at six months follow-up. CONCLUSIONS Half-fluence PDT can be an effective and safe treatment option for peripapillary CCHs which results in both anatomical and functional improvements with no observable complications.
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Affiliation(s)
- Ashok Kumar
- Department of Ophthalmology, Armed Forces Medical College, Pune, 411040, India. .,Department of Ophthalmology, Army College of Medical Sciences & Base Hospital, Delhi Cantt, 110010, India.
| | - Poninder Kumar
- Department of Ophthalmology, Armed Forces Medical College, Pune, 411040, India
| | - Sanjay Kumar Mishra
- Department of Ophthalmology, Army College of Medical Sciences & Base Hospital, Delhi Cantt, 110010, India
| | - Mayank Jhanawar
- Department of Ophthalmology, Army College of Medical Sciences & Base Hospital, Delhi Cantt, 110010, India
| | - Arun Gupta
- Department of Community Medicine, Armed Forces Medical College, Pune, 411040, India
| | - Srikanth Sathagopam
- Department of Ophthalmology, Armed Forces Medical College, Pune, 411040, India
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Gündüz AK, Mirzayev I, Tetik D, Özalp Ateş FS. Circumscribed choroidal hemangioma: Comparative efficacy of transpupillary thermotherapy, indocyanine green-enhanced transpupillary thermotherapy, and photodynamic therapy and analysis of baseline clinical features effecting treatment outcomes. Photodiagnosis Photodyn Ther 2021; 36:102529. [PMID: 34509682 DOI: 10.1016/j.pdpdt.2021.102529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/17/2021] [Accepted: 09/07/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare the efficacy of transpupillary thermotherapy (TTT), indocyanine green-enhanced TTT (ICG-TTT), and photodynamic therapy (PDT) in the management of circumscribed choroidal hemangioma (CCH) and to investigate the baseline clinical features effecting treatment outcomes METHODS: Retrospective review of clinical records of 60 eyes with CCH which underwent TTT (25), ICG-TTT (22), or PDT (13). Main study outcomes were 1) final visual acuity (VA) ≤20/200, 2) <2 Snellen lines VA increase, 3) persistent subretinal fluid (SRF), and 4) <20% decrease in tumor thickness. RESULTS Multivariable factors associated with final VA ≤20/200 included longer duration of symptoms (p = 0.015), lower initial VA (p = 0.030), and presence of retinoschisis overlying the tumor (p = 0.047). Multivariable factors for <2 Snellen lines VA increase were longer duration of symptoms (p = 0.018) and previous failed treatment (p = 0.003). By multivariable analysis, the only significant factor for persistent SRF was the presence of retinoschisis (p = 0.001). Multivariable factors associated with a decrease in tumor thickness by <20% were smaller initial tumor thickness (p = 0.045) and presence of retinoschisis (p = 0.014). By Pearson Chi-Square/Fisher Exact Test, final VA ≤20/200 rates (48.0%, 13.6%, 30.8% respectively, p = 0.041) and VA improvement by <2 lines rates (64.0%, 27.3%, 38.5% respectively, p = 0.036) were significantly different between TTT, ICG-TTT, and PDT groups. However, by post hoc analysis, ICG-TTT yielded statistically better outcomes compared to TTT with respect to final visual acuity (VA) ≤20/200 (p = 0.012) and <2 Snellen lines VA increase (p = 0.012). CONCLUSIONS Longer symptom duration, previous failed treatment, lower initial VA, and presence of retinoschisis were risk factors for worse visual outcomes. Eyes with retinoschisis displayed more SRF persistence after treatment. Smaller initial tumor thickness and presence of retinoschisis were risk factors for <20% decrease in tumor thickness.
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Affiliation(s)
- Ahmet Kaan Gündüz
- Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey; Private Eye Clinic, Ankara, Turkey.
| | - Ibadulla Mirzayev
- Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey; Department of Ophthalmology, Dünyagöz Hospital, Ankara, Turkey
| | - Diğdem Tetik
- Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey
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The Role of Eye Plaque Brachytherapy and MR Imaging in the Management of Diffuse Choroidal Hemangioma: An Illustrative Case Report and Literature Review. Pract Radiat Oncol 2019; 9:e452-e456. [DOI: 10.1016/j.prro.2019.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 11/23/2022]
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Nicolò M, Ghiglione D, Polizzi A, Calabria G. Choroidal Hemangioma Treated with Photodynamic Therapy Using Verteporfin: Report of a Case. Eur J Ophthalmol 2018; 13:656-61. [PMID: 14552602 DOI: 10.1177/112067210301300711] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose To report the results of treatment of circumscribed choroidal hemangioma with a single application of photodynamic therapy (PDT) with verteporfin according to the Treatment of Age-related Macular Degeneration with Photodynamic Therapy study. Methods A 44-year-old man with unilateral decreased vision and macular subretinal fluid secondary to a circumscribed choroidal hemangioma diagnosed by fluorescein and indocyanine green angiography and ultrasonography underwent PDT with verteporfin therapy. Results One year after PDT, subretinal fluid was absent and visual acuity improved. Conclusions The results obtained in this case are in keeping with previously reported results; however, future randomized studies are necessary to evaluate and standardize different infusion times in order to obtain maximum efficacy of treatment.
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Affiliation(s)
- M Nicolò
- Department of Neurology, University Eye Clinic of Genova, Genova, Italy.
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11
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Papastefanou VP, Plowman PN, Reich E, Pavlidou E, Restori M, Hungerford JL, Arora AK, Cohen VML, Sagoo MS. Analysis of Long-term Outcomes of Radiotherapy and Verteporfin Photodynamic Therapy for Circumscribed Choroidal Hemangioma. Ophthalmol Retina 2018; 2:842-857. [PMID: 31047538 DOI: 10.1016/j.oret.2017.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 11/24/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To determine the long-term therapeutic outcome for different treatments of circumscribed choroidal hemangioma (CCH). DESIGN Retrospective observational study. SUBJECTS Patients with newly diagnosed CCH. METHODS Observation, verteporfin (Visudyne) photodynamic therapy (PDT), lens-sparing external beam radiotherapy (LS-EBRT), or plaque brachytherapy. MAIN OUTCOME MEASURES Best-corrected visual acuity (BCVA) at baseline and throughout follow-up, tumor dimensions, and OCT central thickness (where available) at baseline and throughout follow-up were recorded. RESULTS There were 60 treatment-naïve consecutive cases with CCH between January 2000 and June 2014; 42 (70%) received treatment. These were LS-EBRT (23/60 [38%]; mean follow-up, 45.5 months), PDT (16/60 [27%]; mean follow-up, 38 months), and plaque radiotherapy (3/60 [5%]; mean follow-up, 92 months). Macular location, mottled or orange pigment, and absence of drusen were significantly more frequent in the treatment group. In the LS-EBRT group, median thickness reduction on ultrasound B scan was 1.6 mm (mean ± standard deviation, 1.65±1.6; range, -6.5 to +0.7). The mean ± standard deviation BCVA gain was 0.22±0.34, with >3 Snellen lines in 48% of cases. Kaplan-Meier estimates were 80% for any gain and 40% for >3 Snellen lines gain at 5 years. In the PDT group, the median decrease in thickness was 0.95 mm (mean ± standard deviation, 1.0±0.8; range, -2.5 to +0.2). The mean ± standard deviation BCVA gain was at 0.3±0.51, with >3 Snellen lines in 30% of cases. Kaplan-Meier estimates were 93% for any gain and 68% for >3 Snellen lines at 5 years. Double versus single duration PDT had more favorable outcomes with a greater reduction in tumor thickness (P = 0.04), central retinal thickness (P = 0.02), and improvement in visual acuity (median, 0.33 vs -0.05). There was no difference in decrease in tumor thickness or BCVA gain between the LS-EBRT and PDT groups. With plaque brachytherapy, the mean decrease in thickness was 2.5 mm, but BCVA loss of >2 Snellen lines was noted in all 3 cases at the end of follow-up. Radiation complications developed in 10 of 23 cases (43.5%) from the LS-EBRT group and 2 of 3 cases (67%) from the plaque brachytherapy group. CONCLUSIONS LS-EBRT is equivalent to PDT in CCH management for post-treatment BCVA and tumor thickness reduction. The risk of LS-EBRT and plaque brachytherapy was late radiation-related complications. Double duration PDT was more favorable than single duration.
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Affiliation(s)
| | - P Nicholas Plowman
- Department of Radiation Oncology, St. Bartholomew's Hospital, London, UK
| | | | | | - Marie Restori
- Ultrasound Department, Moorfields Eye Hospital, London, UK
| | | | | | | | - Mandeep S Sagoo
- Ocular Oncology Service, London, UK; UCL Institute of Ophthalmology, London, UK
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Maslin JS, Dorairaj SK, Ritch R. Sturge-Weber Syndrome (Encephalotrigeminal Angiomatosis): Recent Advances and Future Challenges. Asia Pac J Ophthalmol (Phila) 2014; 3:361-7. [PMID: 26107979 DOI: 10.1097/apo.0000000000000093] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Sturge-Weber syndrome (SWS) is a congenital, sporadically occurring, neurocutaneous syndrome that presents classically with port-wine stain, leptomeningeal angiomas, and glaucoma. The systemic implications of SWS are vast and involve not only ophthalmic manifestations but also dermatologic, neurologic, and oral manifestations. Neuroimaging, in particular, plays an important role in the diagnosis and management of this disease. Recent discoveries have been made regarding the genetic pathogenesis of SWS. In addition, recent advances have been made in the management of the 2 most common ophthalmic manifestations of SWS: diffuse choroidal hemangioma and glaucoma. Despite these new contributions to the field, many challenges still remain. The management of diffuse choroidal hemangioma is wide ranging and includes photodynamic therapy, brachytherapy, radiotherapy, and antivascular endothelial growth factor injections, but all have had limited or varied success. Although there have been recent advances in knowledge and technique, the management of glaucoma is extremely complex, given the high surgical risks for complications and a poor response rate to medical therapy. Further studies are critical to maximize our knowledge of this difficult disease.
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Affiliation(s)
- Jessica S Maslin
- From the *Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, CT; †Department of Ophthalmology, Mayo Clinic, Jacksonville, FL; and ‡Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai School of Medicine, New York, NY
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Zeisberg A, Seibel I, Cordini D, Lakotka N, Willerding G, Moser L, Heufelder J, Joussen AM. Long-term (4 years) results of choroidal hemangioma treated with proton beam irradiation. Graefes Arch Clin Exp Ophthalmol 2014; 252:1165-70. [DOI: 10.1007/s00417-014-2635-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/02/2014] [Accepted: 04/07/2014] [Indexed: 11/24/2022] Open
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Circumscribed Choroidal Hemangioma. Retina 2013. [DOI: 10.1016/b978-1-4557-0737-9.00153-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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16
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Dorairaj S, Ritch R. Encephalotrigeminal Angiomatosis (Sturge-Weber Syndrome, Klippel-Trenaunay-Weber Syndrome): A Review. ASIA-PACIFIC JOURNAL OF OPHTHALMOLOGY (PHILADELPHIA, PA.) 2012; 1:226-34. [PMID: 26107478 DOI: 10.1097/apo.0b013e31826080a9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sturge-Weber syndrome (SWS) (encephalotrigeminal angiomatosis) is a phakomatosis associated with port-wine stains of the face, seizures, mental retardation, and usually ipsilateral meningeal vascular malformations. The classic form affects leptomeninges, eyes, and face. Although the precise etiology and pathogenesis are unclear, the postulated defect is primary venous dysplasia with failure of the primordial embryonic venous plexus to regress. A spontaneous somatic mutation in fibroblast fibronectin gene expression in the vascular malformation may occur during embryonic development. Ocular involvement is characterized by conjunctival, episcleral, retinal, and choroidal vascular abnormalities. The vascular lesions have been inconsistently described as angiomas, hemangiomas, and vascular malformations. Based on the endothelial cellular activity, they can be considered vascular malformations (or port-wine stains), which never regress spontaneously. Congenital, developmental, and adult-onset glaucoma are often seen when the malformations involve the distribution of the first branch of the trigeminal nerve.Both mechanical and vascular causes have been proposed to account for the development of glaucoma. The mechanical theory is based on obstruction of aqueous outflow secondary to developmental anterior chamber angle abnormalities, and the vascular theory is based primarily on elevated episcleral venous pressure. Management of glaucoma in patients with SWS is often challenging and is aimed at controlling intraocular pressure and preventing progressive visual loss and blindness. It also carries an increased risk for surgical complications. This review summarizes the literature regarding the genetics, clinical features, and management of ocular complications of SWS with special focus on glaucoma.
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Affiliation(s)
- Syril Dorairaj
- From the *Einhorn Clinical Research Center, New York Eye and Ear Infirmary, New York, NY; †Hamilton Glaucoma Center, Shiley Eye Center and Department of Ophthalmology, University of California, San Diego, CA; and ‡Department of Ophthalmology, New York Medical College, Valhalla, NY
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Turell ME, Singh AD. Vascular tumors of the retina and choroid: diagnosis and treatment. Middle East Afr J Ophthalmol 2011; 17:191-200. [PMID: 20844673 PMCID: PMC2934709 DOI: 10.4103/0974-9233.65486] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The vascular tumors of the retina and choroid comprise a diverse group of congenital and acquired lesions. The major vascular tumors of the retina include retinal capillary hemangioma, cavernous hemangioma of the retina, retinal vasoproliferative tumor, and racemose hemangiomatosis of the retina or Wyburn–Mason syndrome. Choroidal vascular tumors include circumscribed choroidal hemangioma and diffuse choroidal hemangioma. While classified as benign, visual symptoms secondary to exudative retinal detachment and a variety of other mechanisms are common and are a major source of long-term visual disability. While many therapeutic modalities exist, treatment of symptomatic cases can be challenging. Of particular importance, many of the vascular tumors of the retina and choroid have significant associations with systemic disease. As ocular symptoms are often the most common presenting disease manifestation, the ophthalmologist plays an important role in accurate and early diagnosis. The ability to initiate prompt screening and treatment in appropriate cases is critical. In the following article, the key clinical and diagnostic features of the major retinal and choroidal vascular tumors, their systemic associations, and the literature pertaining to the most currently available treatment strategies are reviewed.
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Affiliation(s)
- Mary E Turell
- Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Standard versus Bolus Photodynamic Therapy in Circumscribed Choroidal Hemangioma: Functional Outcomes. Eur J Ophthalmol 2011; 21:452-8. [DOI: 10.5301/ejo.2011.6263] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2010] [Indexed: 11/20/2022]
Abstract
Purpose TO compare standard versus bolus photodynamic therapy (PDT) in the treatment of symptomatic circumscribed choroidal hemangioma (CCH). Methods Twenty consecutive cases of CCH were included in this prospective randomized study. Each patient was randomly assigned to receive either standard PDT (10-minute 6 mg/mq2 verteporfin infusion; treatment at 15 min; 50 J/cm2; 83 s) or bolus PDT (6 mg/mq2 verteporfin infusion bolus in 1 min; treatment at 5 min; 100 J/cm2; 166 s). Best-corrected visual acuity (BCVA), fundus photography, optical coherence tomography, fluorescein, and indocyanine green angiography were performed at baseline and during follow-up. Retinal sensitivity was tested with microperimetry before and after treatment. Follow-up was longer than 32 months. Results Mean follow-up was 58±11 months. All cases (100%) showed clinical regression of the treated lesion. Neuroretinal and retinal pigment epithelium (RPE) changes were found in 9 (90%) bolus PDT over treated area. No similar RPE changes were found in patients treated with standard PDT. There was a no statistically significant difference in BCVA outcome between the 2 groups (p=0.078). Microperimetry revealed reduced sensitivity over the treated area in 7 bolus PDT vs 1 in standard treated eyes (p=0.008). Conclusions Both standard and bolus PDT induce regression of symptomatic CCH. Bolus PDT may cause RPE and retinal changes associated with reduced retinal sensitivity.
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Photodynamic therapy of choroidal hemangioma in sturge-weber syndrome, with a review of treatments for diffuse and circumscribed choroidal hemangiomas. Surv Ophthalmol 2010; 56:68-85. [PMID: 21074819 DOI: 10.1016/j.survophthal.2010.08.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 07/30/2010] [Accepted: 08/03/2010] [Indexed: 11/23/2022]
Abstract
We report three new cases of patients with Sturge-Weber Syndrome and symptomatic retinal detachments from diffuse choroidal hemangiomas successfully treated with photodynamic therapy (PDT) and review medical literature on the available treatment options for choroidal hemangiomas. All patients were treated with a single session of PDT with verteporfin infused at a concentration of 6 mg/m(2) and treated for 83 seconds with 689-nm Zeiss laser that was delivered with total energy level of 50 J/cm(2) with an intensity of 600 mW/cm(2). The exudative retinal detachment (RD) and macular edema completely resolved in all cases by 1-4 months after PDT treatment. Visual acuity improved in all three cases with diminished tumor size in the areas of treatment. One case was followed for 5 months, another for 2 years, and the third case for 6 years, with no recurrence of exudative RD. PDT is an effective treatment option for visual deterioration from exudative retinal detachment in patients with diffuse choroidal hemangiomas.
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Kim YT, Kang SW, Lee JI. Gamma knife radiosurgery for choroidal hemangioma. Int J Radiat Oncol Biol Phys 2010; 81:1399-404. [PMID: 20950946 DOI: 10.1016/j.ijrobp.2010.08.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 07/23/2010] [Accepted: 08/06/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE Patients with choroidal hemangioma (CH), a benign ocular hamartoma, frequently presents with visual disturbance as a result of exudative retinal detachment (RD), which originates in subretinal fluid accumulation. We report our experience using the Leksell Gamma Knife in the management of symptomatic CH. METHODS AND MATERIALS Seven patients with symptomatic CH (circumscribed form in 3 patients and diffuse form in 4) were treated with the Leksell Gamma Knife at our institution during a 7-year period. All patients presented with exudative RD involving the macula that resulted in severe visual deterioration. The prescription dose to the target margin was 10 Gy in all cases. The mean tumor volume receiving the prescription dose was 536 mm3 (range, 151-1,057). The clinical data were analyzed in a retrospective fashion after a mean follow-up of 34.4 months (range, 9-76). RESULTS The resolution of exudative RD was achieved within 6 months, and the visual acuity of the affected eye had improved at the latest follow-up examination (p=.018) in all patients. No recurrence of exudative RD occurred. Thinning of the CHs was observed in most patients; however, symptomatic radiation toxicity had not developed in any of the patients. CONCLUSION Symptomatic CHs can be safely and effectively managed with Gamma Knife radiosurgery using a marginal dose of 10 Gy.
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Affiliation(s)
- Yun Taek Kim
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Gambrelle J, Graswill C, Mauget-Faysse M, Kodjikian L, Cochener B, Grange JD. Traitement des hémangiomes choroïdiens circonscrits par photothérapie dynamique : revue de la littérature. J Fr Ophtalmol 2010; 33:497-504. [DOI: 10.1016/j.jfo.2010.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Accepted: 04/30/2010] [Indexed: 10/19/2022]
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Yim JFL, Sandinha T, Kerr JM, Ritchie D, Kemp EG. Treatment review of sight threatening circumscribed choroidal haemangioma. Int J Ophthalmol 2010; 3:168-71. [PMID: 22553545 DOI: 10.3980/j.issn.2222-3959.2010.02.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Accepted: 05/26/2010] [Indexed: 11/02/2022] Open
Abstract
AIM To describe our clinical experience in treating circumscribed choroidal haemangioma (CCH) in a tertiary referral centre over a fifteen year period prior to photodynamic therapy. METHODS The departmental database and photographic records of a tertiary referral center were used to identify patients who were treated for CCH between 1992 and 2007. Their case records were reviewed. RESULTS Visual acuity improved (>2 Snellen lines) in eleven patients (69%) remained stable in one patient (6%) and deteriorated in four patients (25%). Six of the seven treated with brachytherapy and three of the four treated with transpupillary thermotherapy achieved better visual acuity after treatment. 86% of patients treated within six months of onset of symptoms and 50% of patients treated after six months of onset of symptoms noted an improvement in visual acuity. Only one patient in our series had a final VA of 6/60 or worse. Mean follow-up was thirty-five months. CONCLUSION Visual outcome is better when treatment is performed within 6 months of symptoms. The majority of patients achieved an improvement in visual acuity without any adverse effect following treatment.
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Kong DS, Lee JI, Kang SW. Gamma knife radiosurgery for choroidal hemangioma. Am J Ophthalmol 2007; 144:319-22. [PMID: 17659973 DOI: 10.1016/j.ajo.2007.03.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Revised: 03/21/2007] [Accepted: 03/30/2007] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the feasibility of gamma knife radiosurgery (GKS) in the treatment of symptomatic choroidal hemangioma (CH). DESIGN Observational case series. METHODS Three patients who had CH were treated with GKS. Ophthalmologic examinations revealed submacular fluid collection and retinal detachment associated with CH in all cases. GKS was performed as an initial treatment in two cases of circumscribed CH and as secondary treatment after failure of photocoagulation in the other diffuse CH. RESULTS The follow-up period ranged from 18 to 36 months, and visual acuity of the affected eyes was improved in all cases. The volume of CHs and submacular fluid collection were decreased. There were no adverse effects of radiation such as retinopathy or optic neuropathy. CONCLUSIONS GKS may be a useful alternative treatment for symptomatic CHs that are difficult to be managed with a standard therapeutic option such as photocoagulation.
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Affiliation(s)
- Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Anand R, Tasman WS. Nonrhegmatogenous Retinal Detachment. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50129-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Singh AD, Kaiser PK, Sears JE, Gupta M, Rundle PA, Rennie IG. Photodynamic therapy of circumscribed choroidal haemangioma. Br J Ophthalmol 2004; 88:1414-8. [PMID: 15489484 PMCID: PMC1772380 DOI: 10.1136/bjo.2004.044396] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To evaluate efficacy of verteporfin ocular photodynamic therapy (PDT) in treatment of 10 patients with a symptomatic circumscribed choroidal haemangioma. DESIGN Prospective non-randomised, interventional case series and critical review of previously published studies. METHODS 10 consecutive patients (seven primary, two failed transpupillary thermotherapy (TTT), and one failed external beam radiotherapy) with symptomatic circumscribed choroidal haemangioma were treated using verteporfin 6 mg/m2 given as an intravenous infusion over 10 minutes. Diode laser (690 nm) with an intensity of 600 mW/cm2 for 83 seconds (50 J/cm2) was applied 5 minutes after completion of infusion. Single or multiple partially overlapping spots were applied based on the tumour basal dimensions. Periodic follow up with ophthalmoscopy, ultrasonography, and angiographic studies was performed. RESULTS All 10 patients showed evidence of regression with flattening of tumour, resolution of subretinal fluid, and reduction of choroidal vasculature on angiograms. The visual acuity either improved or remained stable in eight (80%) patients. Visual loss due to delayed choroidal atrophy was seen in two patients. CONCLUSIONS Although verteporfin PDT is an effective treatment for management of symptomatic circumscribed choroidal haemangioma, delayed treatment related effects can lead to visual loss.
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Affiliation(s)
- A D Singh
- Department of Ophthalmic Oncology, Cole Eye Institute (i3-129), Cleveland Clinic Foundation, 9500 Euclid Avenue, OH 44195, USA.
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Shields JA, Shields CL, Materin MA, Marr BP, Demirci H, Mashayekhi A. Changing Concepts in Management of Circumscribed Choroidal Hemangioma: The 2003 J. Howard Stokes Lecture, Part 1. Ophthalmic Surg Lasers Imaging Retina 2004. [DOI: 10.3928/1542-8877-20040901-07] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Scott IU, Gorscak J, Gass JDM, Feuer WJ, Murray TG. Anatomic and Visual Acuity Outcomes Following Thermal Laser Photocoagulation or Photodynamic Therapy for Symptomatic Circumscribed Choroidal Hemangioma With Associated Serous Retinal Detachment. Ophthalmic Surg Lasers Imaging Retina 2004. [DOI: 10.3928/1542-8877-20040701-04] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Heufelder J, Cordini D, Fuchs H, Heese J, Homeyer H, Kluge H, Morgenstern H, Höcht S, Nausner M, Bechrakis NE, Hinkelbein W, Foerster MH. [Five years of proton therapy of eye neoplasms at the Hahn-Meitner Institute, Berlin]. Z Med Phys 2004; 14:64-71. [PMID: 15104012 DOI: 10.1078/0939-3889-00190] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Eye tumors (choroidal melanomas, iris melanomas, and choroidal hemangiomas) are being treated with 68 MeV protons since 1998 at the Ion Beam Laboratory of the Hahn-Meitner Institute of Berlin (Germany's first proton therapy center), in cooperation with the Charité University Hospital in Berlin, Campus Benjamin Franklin. The proton beam, generated via a combination of Van de Graaff accelerator and cyclotron, is prepared by passive shaping for conformal tumor irradiation. A digital X-ray verification of the tumor location with the patient in sitting position limits the position uncertainties to a maximum of 0.3 mm. The treatment planning is performed using the program EYEPLAN. OCTOPUS, a CT-based planning program developed in cooperation with the German Cancer Research Center of Heidelberg, is under pre-clinical testing. Thus far, more than 400 patients have been irradiated. The first results are comparable to those obtained in other proton therapy centers. At the end of 2002, the University Hospital of Essen has also become a cooperation partner of the Hahn-Meitner Institute.
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Abstract
Laser photocoagulation and various radiation therapy methods have been used in the treatment of circumscribed choroidal hemangioma that produce visual loss. Recently, transpupillary thermotherapy has been employed in the management of choroidal hemangioma. Thirty-six cases of choroidal hemangioma treated with transpupillary thermotherapy are reviewed. Twenty-eight cases were reported in the literature and 10 cases were managed by the author. Transpupillary thermotherapy has been used as a primary treatment (36 cases) or secondary treatment (2 cases) for choroidal hemangioma. The goal of transpupillary thermotherapy is to achieve resolution of exudative detachment of the fovea and improvement of vision. In all eyes the foveal detachment subsided. In 26 eyes having pretreatment visual acuity >or=0.05 (20/400), the visual acuity increased in 20 (77%) eyes and remained unchanged in 6 (23%) eyes. After transpupillary thermotherapy, 16 (42%) cases showed complete regression, 20 (53%) demonstrated partial regression, and in 2 (5%) there was no change in tumor thickness at follow-ups ranging from 2 to 44 months. Complications of transpupillary thermotherapy of choroidal hemangioma included cystoid macular edema (3 eyes), preretinal fibrosis (2 eyes), focal iris atrophy (3 eyes), and retinal vascular occlusion (1 eye). Although the follow-up in many studies is limited, transpupillary thermotherapy has not been associated with any significant complications.
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Affiliation(s)
- Kaan Gündüz
- Ocular Oncology Service, Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey.
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Gupta M, Singh AD, Rundle PA, Rennie IG. Efficacy of photodynamic therapy in circumscribed choroidal haemangioma. Eye (Lond) 2004; 18:139-42. [PMID: 14762404 DOI: 10.1038/sj.eye.6700597] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To report efficacy of photodynamic therapy (PDT) in the treatment of three cases of juxtafoveal circumscribed choroidal haemangioma. METHODS Data on three patients (two primary, and one failed TTT) treated with verteporfin, 6 mg/m2 given as i.v. infusion over 10 min. Diode laser (690 nm) with an intensity of 600 mW/cm2 for 83 s (50 mJ/cm2) was applied 5 min after completion of infusion. Overlapping multiple spots (2500 microm) were applied to cover the entire surface of the tumour. The mean pretreatment tumour size was 7 mm (base) x 2.2 (thickness) mm. Periodic follow-up with ophthalmoscopy, ultrasonography, and angiographic studies was performed. RESULTS All three cases showed complete regression of the tumour with resolution of subretinal fluid, flattening of tumour, and absence of choroidal vasculature on ICG. The visual acuity either improved or remained stable in all three cases. The overlying retinal vessels remained unaffected. There were no ocular or systemic complications. CONCLUSIONS PDT is an effective treatment for management of juxtafoveal circumscribed choroidal haemangioma.
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Affiliation(s)
- M Gupta
- Oncology Service, Department of Ophthalmology, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK
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Affiliation(s)
- Richard F Spaide
- Vitreous-Retina-Macula Consultants of New York, P.C., New York, New York 10021, USA.
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Kivelä T, Tenhunen M, Joensuu T, Tommila P, Joensuu H, Kouri M. Stereotactic radiotherapy of symptomatic circumscribed choroidal hemangiomas. Ophthalmology 2003; 110:1977-82. [PMID: 14522774 DOI: 10.1016/s0161-6420(03)00483-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To determine feasibility of low-dose stereotactic radiotherapy in the treatment of symptomatic circumscribed choroidal hemangioma. DESIGN Prospective, noncomparative, interventional case series. PARTICIPANTS Five consecutive patients with perifoveolar and peripapillary circumscribed choroidal hemangioma and visual symptoms from exudative retinal detachment. METHODS A dose of 20 Gy was delivered stereotactically with linear accelerator. Tumor dimensions were determined by B-scan ultrasonography. MAIN OUTCOME MEASURES Resolution of subretinal fluid, best-corrected visual acuity, and reduction in tumor height. RESULTS Median tumor height at baseline was 2.8 mm (range, 2.0-4.2 mm). Two tumors were subfoveolar, two were juxtafoveolar, and one was extrafoveolar. Cystic macular edema and subretinal fibrosis were present in both eyes with subfoveolar tumor. Exudative retinal detachment resolved within a median of 5 months (response rate, 100%; 95% CI, 48%-100%). Median best-corrected visual acuity was 20/50 (range, 20/22-20/100) at diagnosis and 20/25 (range, 20/20-20/60) 20 months after treatment. Tumor height had decreased a median of 24% (range, 0%-31%) by 6 months and 29% (range, 9%-59%) by 20 months. Secondary retinal pigment epithelial mottling associated with tumor regression occurred in two patients. One eye developed a paracentral scotoma. CONCLUSIONS Stereotactic radiotherapy can be targeted precisely enough to induce regression of subretinal fluid from circumscribed choroidal hemangiomas.
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Affiliation(s)
- Tero Kivelä
- Oncology and Vitreoretinal Service, Department of Ophthalmology, Helsinki University Central Hospital, Haartmaninkatu 4 C, PL 220, FIN-00029 HUS, Helsinki, Finland
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Abstract
Circumscribed choroidal hemangioma is an uncommon, benign vascular tumor manifesting as an orange-red mass in the posterior pole of the eye. Serous retinal detachment accounts for decreased vision in most patients. Diagnosis of this tumor is challenging with many patients initially misdiagnosed with choroidal melanoma or metastasis. Several ancillary tests such as ultrasonography, fluorescein angiography, indocyanine green angiography, and magnetic resonance imaging help differentiate this tumor from other simulating lesions. Asymptomatic lesions should be observed, but visually threatening or visually impairing lesions require treatment. Photodynamic therapy, laser photocoagulation, and transpupillary thermotherapy may be used for primary management of this tumor. Patients who fail to respond to previous treatment or those with extensive serous retinal detachment can be treated using radiotherapeutic modalities. Long interval between onset of symptoms and treatment, poor visual acuity at presentation, and presence of chronic retinal or retinal pigment epithelial changes are associated with poor long-term vision.
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Affiliation(s)
- Arman Mashayekhi
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Porrini G, Giovannini A, Amato G, Ioni A, Pantanetti M. Photodynamic therapy of circumscribed choroidal hemangioma. Ophthalmology 2003; 110:674-80. [PMID: 12689885 DOI: 10.1016/s0161-6420(02)01968-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To evaluate the safety and effectiveness of photodynamic therapy (PDT) in the treatment of symptomatic circumscribed choroidal hemangiomas (CCH) of the posterior pole. DESIGN Prospective, consecutive, noncomparative case series. PARTICIPANTS Ten eyes of 10 patients (six males and four females; age range, 38-64 years) reporting visual impairment caused by intraocular CCH. Follow-up was 7 to 16 months. METHODS Photodynamic therapy was applied by Zeiss laser (Visulas 6905, Carl Zeiss-Meditech AG, Jeud Germany) emitting a light at 689 nm for photosensitization and by using verteporfin (Visudyne; Novartis Ophthalmics AG, Basel, Switzerland) at a dose of 6 mg/m(2) body surface administered intravenously before treatment. The diameter of the treatment spot was calculated on early frames of pretreatment indocyanine green angiography; the maximum treatment spot diameter was 6000 micro m using a Mainster wide-field lens (Ocular Instruments Inc., Bellevue, WA USA). In the case of peripapillary CCH, the laser spot was applied at a distance of 200 micro m from the optic disc edge. A laser beam was applied to the retina 15 minutes after the start of the infusion. Two different treatment procedures were used according to the height of the lesion. A radiant exposure of 100 J/cm(2) with an exposure time of 186 seconds was applied to lesions larger than 2 mm. For lesions smaller than 2 mm, a radiant exposure of 75 J/cm(2) with an exposure time of 125 seconds was used. MAIN OUTCOME MEASURES Visual outcomes, pretreatment findings, and final findings were evaluated using biomicroscopy, fluorescein angiography (FA), indocyanine green angiography (ICGA), and ultrasound. RESULTS After a follow-up of 7 to 16 months, FA and ICGA verified the nonperfusion of the vascular channels of the tumor in the treated areas. No retinal pigment epithelium (RPE) changes were observed in the patients who had undergone two PDT treatments, whereas minimal alterations were detected in two of the four patients who had undergone three treatment sessions. Angiographic cystoid macular edema and exudative macular detachment had completely regressed in all cases. Minimal intraretinal edema was observed on the FA frames in two cases. Ultrasound examination found no measurable tumor height in six (60%) cases and a marked reduction in the remaining four cases, even after one treatment (post treatment tumor height range, 0.86-1.82 mm). An improvement in visual acuity (one to six lines on the Early Treatment for Diabetic Retinopathy Study chart) was observed in all the cases. In four cases, the visual acuity returned to 20/20, of which three were extrafoveal and one was subfoveal with visual impairment caused by secondary exudative macular detachment without significant RPE alterations. Also in longstanding subfoveal cases, a marked visual acuity improvement was detected resulting from the disappearance of subretinal or intraretinal fluid, even if functional results were limited by pre-existing RPE alterations. In all cases no damage to retinal vessels was observed. CONCLUSIONS Photodynamic therapy is a minimally invasive but effective method of treatment for CCH and may be considered as a treatment of choice, especially in patients with foveal location of the tumor. Because of its safety and repeatability, this technique can be used to treat frequent recurrences of the tumor.
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Jurklies B, Anastassiou G, Ortmans S, Schüler A, Schilling H, Schmidt-Erfurth U, Bornfeld N. Photodynamic therapy using verteporfin in circumscribed choroidal haemangioma. Br J Ophthalmol 2003; 87:84-9. [PMID: 12488269 PMCID: PMC1771447 DOI: 10.1136/bjo.87.1.84] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To investigate the safety and efficacy of photodynamic therapy with verteporfin in patients with choroidal haemangioma. METHODS A non-randomised, prospective clinical investigation of 19 patients with symptomatic circumscribed choroidal haemangioma was performed. Unsuccessful pretreatment (external beam irradiation, laser photocoagulation) was performed in four patients. Patients were included when (1) subretinal exudation involving the fovea, (2) a decrease in visual function, and (3) additional symptoms (for example, metamorphopsia) were present. Photodynamic therapy (PDT) was performed with verteporfin at a concentration of 6 mg/m(2) body surface area and a light dose of 100 J/cm(2) at 692 nm. RESULTS The mean follow up time was 10.6 months (2-24 months). The mean number of treatment sessions was 2.15 (range 1-5). Visual acuity improved by at least one line in 73.3%, by at least two lines in 42.1%, was stable in 21.1%, and decreased by one line in 5.2% of the patients. Exudation was completely resolved in 94.8% of the cases. Regression of tumour height was documented in all 19 tumours. Patients receiving any pretreatment before PDT, a visual acuity of 0.1 and less, a history of more than 30 months, and no significant response after the first PDT session, did not show any significant improvement. Cox regression analysis revealed that the number of PDT treatment sessions was inversely associated with the improvement in visual acuity of at least two lines. No recurrences and no local or systemic side effects were observed during the follow up time. CONCLUSION PDT using verteporfin is a safe and effective therapy for the treatment of symptomatic choroidal haemangioma even in tumours located beneath the fovea.
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Affiliation(s)
- B Jurklies
- Department of Ophthalmology, Univ-Hospital Essen, Germany Department of Ophthalmology, Univ-Hospital Lübeck, Germany.
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Ritland JS, Eide N, Tausjø J. External beam irradiation therapy for choroidal haemangiomas. Visual and anatomical results after a dose of 20 to 25 Gy. ACTA OPHTHALMOLOGICA SCANDINAVICA 2001; 79:184-6. [PMID: 11284760 DOI: 10.1034/j.1600-0420.2001.079002184.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate the visual and anatomic results of radiation therapy in ten patients with choroidal haemangiomas. METHODS Nine patients with circumscribed choroidal haemangiomas and one with diffuse choroidal haemangioma have been reviewed retrospectively. They were treated by lens-sparing external beam radiation therapy (20--24 Gy) (9 eyes) and plaque brachytherapy (25 Gy) (1 eye), respectively. RESULTS The visual acuity improved by two lines or more in 8 of 10 eyes. No eyes showed deterioration of visual acuity. In all cases the retinal detachment showed complete resolution. A regression in tumour thickness was observed in all cases, and a reduction of anisometropia in cases with submacular infiltration by the tumour. During follow-up (0.4--8.8 years) there were no signs of radiation cataract, retinopathy or optic neuropathy. CONCLUSIONS External beam radiation (20--25 Gy) is a reasonable alternative for treatment of symptomatic choroidal haemangiomas.
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Affiliation(s)
- J S Ritland
- University Eye Department, The National Hospital, University of Oslo, Norway
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Char DH, Irvine AI, Posner MD, Quivey J, Phillips TL, Kroll S. Randomized trial of radiation for age-related macular degeneration. Am J Ophthalmol 1999; 127:574-8. [PMID: 10334351 DOI: 10.1016/s0002-9394(99)00038-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess external beam radiation efficacy for subfoveal neovascularization associated with age-related macular degeneration. METHODS All patients were evaluated in the same institution. In this prospective trial, 27 eyes (27 patients) with subfoveal neovascularization associated with age-related macular degeneration were randomized to either single fraction radiation (750 centigray) or observation. Endpoints were assessed by fluorescein angiography and Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity. Examiners were masked to patient treatment status. Parametric and nonparametric statistical analyses were performed. RESULTS Twenty-seven patients were entered into the trial with a mean age of 76 years (range, 64 to 89) and a mean follow-up of 17 months (range, 7 to 32). The visual acuity loss was slightly less in the irradiated group, a finding of borderline significance (P < .046). There was no significant difference in fluorescein angiographic evidence of subretinal neovascular membrane change in the control group vs the irradiated group. CONCLUSIONS External beam radiation, at this dose and fractionation, did not appear harmful. There was slightly less visual loss in irradiated eyes. No difference in fluorescein angiographic characteristics of subfoveal neovascularization size or progression in eyes with age-related macular degeneration was noted.
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Affiliation(s)
- D H Char
- Tumori Foundation, California Pacific Medical Center, San Francisco, USA
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