Photodynamic therapy for choroidal neovascularization associated with choroidal osteoma

[Long-term outcome of macular neovascularization secondary to choroidal osteoma with and without intravitreal anti-VEGF(vascular endothelial growth factor)- treatment]

BACKGROUND

Choroidal osteoma (CO) is a benign ossifying ocular tumor, which is unilateral in most cases. The CO may cause severe visual impairment, especially in the case of a secondary macular neovascularization (MNV).

OBJECTIVE

Based on a case series of patients with MNV secondary to CO, the variability of the clinical course with and without intravitreal anti-vascular endothelial growth factor (VEGF) treatment is presented.

METHODS

All patients diagnosed with secondary MNV due to CO between 2007 and 2023 were retrospectively assessed with respect to the clinical course.

RESULTS

In this study 7 eyes of 5 patients (4 women, 1 man) were diagnosed with secondary MNV due to CO. Intravitreal anti-VEGF treatment was carried out in 2 patients with unilateral MNV and 1 patient was treated in both eyes for bilateral MNV. In another case with bilateral MNV, only 1 eye was treated because of fibrosis in the other eye. A further case with unilateral CO and MNV scars at the initial diagnosis was left untreated. Overall, in 3 out of 5 eyes treated with intravitreal VEGF inhibition stabilization or improvement of visual acuity could be achieved.

CONCLUSION

In our case series intravitreal anti-VEGF treatment attained a functional stabilization or improvement in 3 out of 5 treated eyes. In one case of CO-associated MNV fibrosis rapidly developed without treatment. Therefore, the clarification for patients with CO about the lifelong risk for development of a secondary MNV is essential in individual cases for early treatment. As no standardized treatment scheme for intravitreal VEGF antibodies for CO-related MNV exists, the treatment is planned on an individual basis.

Clinical features and therapeutic management of choroidal osteoma: A systematic review

Choroidal osteoma is a benign ossifying tumor within the choroid. Complications associated with choroidal osteoma, including disruption of retinal pigment epithelium, atrophy of photoreceptors, subretinal fluid, and choroidal neovascularization, present challenges for clinicians, and management remain controversial. We performed a comprehensive search in the PubMed, EMBASE, and Ovid databases for published studies and case reports relating to the management of choroidal osteoma. Since it was first described in 1978, various case reports of ocular complications associated with choroidal osteoma have been documented, and various therapies have yielded different outcomes. We systematically evaluate the literature published on this rare entity.

Appearance of Tumor Vessels in Patients With Choroidal Osteoma Using Swept-Source Optical Coherence Tomographic Angiography

Objective

To report the morphologic characteristics of tumor-related vasculatures and their association with secondary choroidal neovascularization (CNV), subretinal fluid (SRF), choroidal thickness, retinal pigment epithelium (RPE) alterations, subretinal hemorrhage, and tumor decalcification in eyes with choroidal osteoma (CO), using swept-source optical coherence tomographic angiography (SS-OCTA).

Design

Cross-sectional observational study.

Participants

We included 26 patients recruited from Beijing Tongren Hospital with a diagnosis of CO, based on the presence of yellow-orange mass deep to the RPE under indirect ophthalmoscopy and occupying the choroid with well-defined margins and bone density on ultrasonography or computed tomography and focal hyperfluorescent spots with no homogeneous pattern on fluorescein angiography/indocyanine green angiography (FA/ICGA). Data were collected from April 1, 2020, to April 1, 2021, and analyzed from April 30 through May 30, 2021.

Methods

Applying SS-OCTA systems operating at 1,050-nm wavelengths, eyes with CO were imaged.

Main Outcome and Measures

Tumor-related vasculature in eyes with CO was characterized using multimodal imaging that included fundus photography, FA/ICGA, SS-OCT, and SS-OCTA, and the images were anatomically aligned. CO thickness was manually measured as the distance between the upper boundary of the tumor and the underlying sclerochoroidal interface on the SS-OCT images. Subfoveal choroidal thickness was manually measured as the distance between the Bruch membrane and the sclerochoroidal interface on the SS-OCT images.

Results

Of the 26 Asian patients, 16 (62%) were women and 10 (38%) were men. The mean age was 26.8 years (median, 23; range, 8–45 years), and the mean best corrected visual acuity (BCVA) was 20/40. Thirty-three eyes underwent imaging and were diagnosed with CO. Indocyanine green angiography identified inhomogeneous hyperfluorescence due to tumor-related vasculature, and all corresponded to the structures that appeared as sea-fan vascular networks (SFVNs) combined with clusters of tangled vessels on SS-OCTA images. SFVNs were detected on SS-OCTA imaging in all eyes (100%), terminal tangled vascular structures in 32 of 33 eyes (97%), but not identified on ICGA. Of the 33 tangled vascular structures, 32 (97%) were located at the edge of or inside the tumor, and only 1 (3%) was associated with type 2 neovascularization. In addition, SS-OCT revealed SRF in 33 eyes (100%), 33 (100%) were located at the edge of CO, and only 1 was underlying macular. SRF with retinal edema was seen in 30 of 32 eyes (94%).

Conclusions

In eyes with CO undergoing SS-OCTA imaging, tumor-related vasculature appears as SFVNs combined with tangled vascular structures or few type 2 neovascularization. The identification of actual tumor vasculature in patients with CO as SFVNs with inner or terminal vascular tangles rather than previously described CNV may help facilitate understanding of their pathogenesis, tumor control, and response to treatment.

Choroidal neovascularization due to choroidal osteoma treated with anti-vascular endothelial growth factor therapy: An optical coherence tomography angiography study

PURPOSE

To evaluate the response to anti-vascular endothelial growth factor therapy for choroidal neovascularization secondary to choroidal osteoma using optical coherence tomography angiography.

METHODS

This retrospective study included four eyes of four females with choroidal osteoma complicated by choroidal neovascularization, treated with ranibizumab. All patients underwent full ophthalmologic examination, including ocular ultrasound, retinography, fluorescein angiography, spectral-domain or swept-source optical coherence tomography, and optical coherence tomography angiography. These images were analyzed to measure choroidal osteoma and to study choroidal neovascularization changes after intravitreal anti-vascular endothelial growth factor.

RESULTS

In all cases, fluorescein angiography revealed the presence the choroidal neovascularization, as an early hyperfluorescence area increasing during the exam. Optical coherence tomography showed both the choroidal osteoma and choroidal neovascularization and intra- or subretinal fluid as activity sign. In optical coherence tomography angiography, choroidal osteoma vessels were valuable in outer retina and choroidal slabs, and were irregular and did not change after ranibizumab injection; neovascular network correlating with choroidal neovascularization showed a hyperflow tangled vessels in outer retina, decreasing in density after anti-vascular endothelial growth factor therapy.

CONCLUSION

Optical coherence tomography angiography seems to be a useful tool in visualizing and distinguishing vascular networks of choroidal osteoma and of choroidal neovascularization secondary to choroidal osteoma better than fluorescein angiography.

Intravitreal bevacizumab monotherapy for choroidal neovascularisation secondary to choroidal osteoma

PurposeThe purpose of this study is to present the outcomes of a series of patients with choroidal neovascular membrane (choroidal neovascularisation (CNV)) secondary to a choroidal osteoma undergoing anti-VEGF monotherapy.Patients and methodsRetrospective series of patients with choroidal neovascularization secondary to choroidal osteoma. All patients underwent clinical and imaging assessment (fundus photo, B-scan ultrasonography, fluorescein angiography, and optical coherence tomography-where available), and were managed with intravitreal anti-VEGF injections (Bevacizumab). Visual acuity and central retinal thickness were recorded pre treatment and at the end of the follow-up period.ResultsEight patients were included in this study. Of this, 6/8 had predominantly classic or classic and 2/8 patients had minimally classic or occult CNV. Each patient received 3-10 injections of bevacizumab. Median follow-up was 9 months (3-15 months). Visual acuity improved in 5 patients, by 2-6 Snellen lines. CNV completely regressed in 5 cases and partially regressed in 3 cases. Mean CRT reduction was 122 μm (6 to -230 μm).ConclusionIntravitreal bevacizumab can be an effective treatment modality in the management of vision threatening CNV secondary to choroidal osteoma.

Real-time in vivo micromorphology and histopathology of choroidal osteoma using enhanced depth imaging

Choroidal osteoma is a usually unilateral benign tumor of the choroid composed of mature bone. Optical coherence tomography (OCT) has been used to image osteoma for several years. With the advent of enhanced depth imaging (EDI) feature of spectral-domain OCT (SD-OCT), better visualization of the morphology of choroidal lesions has been possible. Herein we present a case of choroidal osteoma in a 45-year-old woman, wherein in vivo morphology of the choroidal osteoma had been visualized using EDI technique of SD-OCT before and after performing photodynamic therapy. EDI OCT has proven to be a valuable noninvasive imaging modality, almost comparable to histopathological examination, for diagnosing choroidal osteomas and for providing an insight into the in vivo micromorphological changes occurring during the course of the disease.

Long-term outcomes of intravitreal injection of bevacizumab for choroidal neovascularization associated with choroidal osteoma

Purpose

To describe the outcomes of intravitreal injections of bevacizumab for choroidal neovascularization (CNV) associated with choroidal osteoma.

Methods

Retrospective consecutive case series. Three eyes of three patients were studied. All patients were treated with intravitreal injections of bevacizumab for CNV associated with choroidal osteoma. Best-corrected visual acuity, central foveal thickness, tumor thickness on spectral domain optical coherence tomography, and subretinal pigmentation around the CNV were evaluated.

Results

The mean number of intravitreal injections of bevacizumab was 2.0 (range 1–3). The mean follow-up time was 56.0 months (range 25–99 months). The mean LogMAR visual acuity worsened from 0.1 to 0.6. LogMAR visual acuity loss of 0.7 or worse occurred in two of three eyes. CNV was located in the subfoveal area in two eyes, and CNV was located in the juxtafoveal area in one eye. The mean central foveal thickness decreased from 407 μm to 251 μm. The mean tumor thickness decreased from 709 μm to 608 μm. All eyes had subretinal pigmentation around the CNV.

Conclusion

Intravitreal injections of bevacizumab for subfoveal CNV associated with decalcified choroidal osteoma resulted in poor visual acuity.

Review of choroidal osteomas

Choroidal osteomas are rare benign ossifying tumors that appear as irregular slightly elevated, yellow-white, juxtapapillary, choroidal mass with well-defined geographic borders, depigmentation of the overlying pigment epithelium; and with multiple small vascular networks on the tumor surface. Visual loss results from three mechanisms: Atrophy of the retinal pigment epithelium overlying a decalcified osteoma; serous retinal detachment over the osteoma from decompensated retinal pigment epithelium, and most commonly from choroidal neovascularization. Recent evidence points to the beneficial effects of intravitreal vascular endothelial growth factor antagonists in improving visual acuity in serous retinal detachment with or without choroidal neovascularization.

Bilateral choroidal osteoma with choroidal neovascular membrane treated with bevacizumab in a child

Choroidal osteoma is a rare benign tumor. We report a male child diagnosed with bilateral choroidal osteoma, high myopia and secondary choroidal neovascularization (CNV) membrane in one eye. Co-existence of posterior staphyloma made the clinical diagnosis of choroidal osteoma difficult due to the osteoma filling the depression of the posterior staphyloma. Typical findings on fundus fluorescein angiography, optical coherence tomography, B-scan and indocyanine green angiography confirmed the diagnosis. A review of literature was performed. CNV secondary to choroidal osteoma was treated with intravitreal bevacizumab and it responded well. Regular follow-up is essential for recurrence of CNV and decalcification of the osteoma.

Role of Intravitreal Antivascular Endothelial Growth Factor Injections for Choroidal Neovascularization due to Choroidal Osteoma

We treated 26 eyes of 25 young patients having a mean age of 30 years with intravitreal vascular endothelial growth factor (VEGF) inhibitor for choroidal new vessel (CNV) formation overlying choroidal osteoma over a mean follow-up of 26 months. Mean number of injections was 2.4 at 6 months, 3.2 at 12 months, and 5.5 at 24 months. CNV was subfoveal in 14 eyes, juxtafoveal in 5, extrafoveal in 5, and peripapillary in 2. By paired comparison, mean decrease from baseline was 119.7 microns at 6 months (n = 15; P = 0.001), 105.3 microns at 1 year (n = 10; P = 0.03), and 157.6 microns at 2 years (n = 7; P = 0.08). BCVA improved by 3.3 lines at 6 months after therapy (n = 26; P < 0.001), 2.8 lines (n = 20; P = 0.01) at 1 year, and 3.1 lines (n = 13; P = 0.049) at 2 years. We conclude that intravitreal anti-VEGF injections improve vision in majority of eyes with CNV from choroidal osteoma.

Diagnosis and Monitoring of Choroidal Osteoma through Multimodal Imaging

A 16-year-old Caucasian female with a 6-month history of decreased visual acuity and metamorphopsia in the left eye is reported. The fundus of the left eye revealed a well defined lesion in the macula region. Diagnosis of choroidal osteoma was established using spectral domain optical coherence tomography (OCT), fundus fluorescein angiography (FFA), indocyanine green angiography (ICG), and B-scan ultrasonography. Subretinal fluid (SRF) and retinal pigment epithelium (RPE) detachment were noted in the absence of obvious classic choroidal neovascularisation (CNV). The patient was followed up for over 13 months without any treatment in the interim and the lesion was noted to have enlarged but visual acuity and SRF had remained stable. We report an interesting case where subretinal fluid was noted in the absence of evident choroidal neovascularisation and provide an example of the imaging modalities application in the era of “optical biopsy.”

Photodynamic therapy combined with intravitreal bevacizumab in a patient with choroidal neovascularization secondary to choroidal osteoma

Choroidal osteoma is a benign ossified tumor that is found predominantly in healthy young women during their second and third decades of life. The lesions are white-to-cream or orange in color, are located in the peripapillary and macular areas, and are unilateral in most patients. The symptoms of choroidal osteoma include decreased visual acuity and metamorphopsia or scotoma corresponding to the location of the osteoma, but some patients have no symptoms. Prognosis of vision varies according to tumor location, retinal pigment epithelial and sensory retinal degeneration, subretinal fluid and hemorrhage, and development of a subretinal neovascular membrane.

[Intravitreal injection of bevacizumab for CNV secondary to choroidal osteoma and follow-up by Spectral-Domain OCT]

BACKGROUND

Choroidal osteoma is a rare, ossifying tumor, which, while benign, may be complicated by choroidal neovascularization.

METHODS

An 11-year-old boy presented with blurred vision in the right eye for few days. Fundus examination showed bulky lesion in the posterior pole containing a sub-retinal hemorrhage. The geographic borders and color of the mass were typical of choroidal osteoma despite the unusual macular location. The diagnosis was confirmed by ultrasonography. The patient was treated with three successive intravitreal injections of 1.25 mg/0.05 mL bevacizumab (IVB) under general anesthesia, due to recurrences of neovascular activity. SD-OCT in EDI mode was carried out prior to each injection.

RESULTS

SD-OCT before and after each bevacizumab injection confirmed regression of serous retinal detachment (SRD) at various locations throughout the lesion, especially in the hemorrhagic zone. It also allowed us to differentiate the active decalcified zones from the inactive calcified zones and to follow treatment response.

DISCUSSION

The treatment of choroidal neovascularization (CNV) secondary to choroidal osteoma is not well defined. As for other etiologies of CNV, anti-VEGF agents (such as bevacizumab) appear to be effective in regressing CNV and improving visual function. In our young patient, general anesthesia was necessary to administer each injection. SD-OCT allows diagnostic confirmation and follow-up of treatment. EDI mode is helpful in studying the choroid and the osteoma.

CONCLUSION

We report a rare case of macular choroidal osteoma, examined by SD-OCT. CNV required several anti-VEGF injections, with good anatomical and functional results.

Combination therapy of low-fluence photodynamic therapy and intravitreal ranibizumab for choroidal neovascular membrane in choroidal osteoma

Choroidal osteoma is an unusual form of intraocular calcification seen in otherwise healthy eyes. It is a benign idiopathic osseous tumor of the choroid, typically seen in young females. Choroidal neovascular membrane (CNVM) is a complication seen in one-third of these patients and carries a poor visual outcome. We report a case of a 25-year-old hyperthyroid female with choroidal osteoma and subfoveal CNVM in her left eye which was successfully treated using low-fluence photodynamic therapy (PDT) with verteporfin followed by a single injection of intravitreal ranibizumab.

Long-term success of intravitreal bevacizumab for choroidal neovascularization associated with choroidal osteoma

PURPOSE

To describe a case of choroidal osteoma with choroidal neovascularization (CNV) that was successfully treated with two intravitreal injections of bevacizumab (IVB).

DESIGN AND METHODS

Case report on a 12-year-old Japanese girl who presented with a sudden decrease in vision in her left eye. At the first visit, 2 days after the onset of her symptoms, her visual acuity (VA) in her left eye was 0.2. Ophthalmoscopy showed a hemorrhage of 5 disc diameters under the retinal pigment epithelium and a serous retinal detachment at the posterior pole of the left eye. These findings were confirmed by optical coherence tomography. Fluorescein angiography (FA) and indocyanine green angiography (ICGA) showed several points of leakage around the fovea, which suggested a CNV. From these findings, the patient was diagnosed with choroidal osteoma with a CNV. The submacular hemorrhage was from the CNV associated with the choroidal osteoma. We treated her with two injections of 1.25 mg/0.05 mL IVB with a 4-month interval.

RESULTS

The patient's VA in her left eye improved to 0.7, and this vision was maintained for 4 years. The CNV disappeared in the FA and ICGA images and no recurrence was observed after 4 years.

CONCLUSION

Our findings indicate that IVB is effective in resolving CNV in eyes with an osteoma and prevents a decrease of vision in eyes with a choroidal osteoma with a CNV.

Dramatic response of choroidal neovascularization associated with choroidal osteoma to the intravitreal injection of bevacizumab (Avastin)

PURPOSE

To report the dramatic response of juxtafoveal choroidal neovascularization (CNV) associated with choroidal osteoma to a single intravitreal injection of bevacizumab.

METHODS

A 19-year-old female presented with decreased visual acuity and metamorphopsia in her right eye. Best corrected visual acuity assessment, ophthalmic examination, fundus photography, fluorescein angiography, optical coherence tomography (OCT), and high-resolution computed tomography (CT) scan of the orbit was performed. A diagnosis of classic juxtafoveal CNV associated with choroidal osteoma was made. Intravitreal injection of 1.25 mg of bevacizumab was performed.

RESULTS

Visual acuity of the right eye was 20/200 before treatment. Visual improvement to 20/25 and the resolution of metamorphopsia was noticed six weeks after the intravitreal injection of bevacizumab. Regression of the CNV was confirmed according to ophthalmoscopic, fluorescein angiographic, and OCT findings. The treatment effect persisted during a 9-month follow-up period.

CONCLUSION

The intravitreal injection of bevacizumab can result in the rapid regression of CNV secondary to choroidal osteoma.

Choroidal osteoma: evidence of progression and decalcification over 20 years

Choroidal osteoma is a rare, benign, ossifying tumour of the choroid of unknown aetiology. In contrast to other types of intraocular ossification, choroidal osteoma is found typically in young healthy females in the second or third decades of life with no history of systemic or ocular disease. Choroidal osteoma is a deep, pale yellow lesion with distinct geographic borders at the juxtapapillary or macular region, with branching 'spider' vessels on the surface of the tumour. These features should help differentiate choroidal osteoma from other types of intraocular tumour and the diagnosis can be confirmed with ultrasonography and computerised tomography. Here we report an initially unilateral case of choroidal osteoma, which decalcified over 20 years but during the same period the fellow eye also developed a choroidal osteoma to become a bilateral case. Despite the benign nature of the tumour, vision may be compromised by gradual atrophy of the overlying retina, serous retinal detachment, accumulation of sub-retinal fluid and sub-retinal haemorrhage associated with choroidal neovascularisation. Frequent examinations are recommended for patients with choroidal osteoma, for early detection of a subretinal neovascular membrane and potential treatment with laser photocoagulation.

Photodynamic therapy for inflammatory choroidal neovascularisation unresponsive to immunosuppression

AIM

To report on visual and angiographic outcomes of a consecutive series of patients with inflammatory choroidal neovascular membranes (CNV) unresponsive to systemic immunosuppression treated with photodynamic therapy (PDT).

METHODS

The medical records of six consecutive patients with inflammatory CNVs that failed to respond to systemic immunosuppression and that later underwent PDT were retrospectively reviewed. Patient demographics, visual acuity, and fluorescein angiographic findings were evaluated.

RESULTS

There were five females and one male with a mean age of 40.8 years (range 35-58 years). Four patients had clinical features consistent with punctate inner choroidopathy and two with presumed ocular histoplasmosis. In all cases clinical signs of CNV activity, including subretinal fluid, subretinal blood, hard exudates, and/or recent decrease in visual acuity were present prior to PDT. All patients had been treated with high dose systemic immunosuppressants, which failed to induce regression of the CNV and/or to improve vision. The CNVs were subfoveal in five patients and juxtafoveal in one; all were classified as predominantly classic. Following PDT an improvement in vision occurred in all cases (median improvement of 18 letters, range 3-42 letters). At last follow up, signs of decreased activity in the CNV were detected in all cases. Patients were followed for a median of 10 months (range 9-20 months).

CONCLUSION

PDT appears to be a useful option in the management of patients with inflammatory CNVs unresponsive to immunosuppressive therapies.

Midperipheral mottling pigmentation with familial choroidal osteoma

PURPOSE

To describe a rare presentation of familial choroidal osteoma in two siblings.

METHODS

The clinical findings in two siblings over 4 years' follow-up.

RESULTS

Two brothers (15 and 12 years old) had bilateral choroidal osteomas. Both had bilateral peripapillary yellowish-white lesions and midperipheral mottling pigment appearance, which are not seen in sporadic cases. Extensive midperipheral area with mottling pigment appearance was noted by fluorescein angiography (FA) as scattered multiple hyperfluorescent dots. The yellowish-white lesions showed diffuse hyperfluorescence with FA and hypofluorescence with indocyanine green angiography (ICG). ICG also revealed irregular hyperfluorescent areas within the tumor, indicating abnormal choroidal vessels on the tumor. In the left eye of the younger brother, the subretinal fibrosis due to choroidal neovascularization superior to the macula extended down toward the foveal region over 2 years, resulting in visual deterioration.

CONCLUSION

The midperipheral mottling pigment appearance of familial choroidal osteoma cases is unique and different from most sporadic cases, suggesting that familial choroidal osteoma might have separate etiologic or modified factors.

Choroidal osteoma: observations from a community setting

PURPOSE

To determine the characteristics of choroidal osteoma arising from a previously unreported patient population and to document new observations in this condition.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Eleven consecutive patients seen from 1986 through 2002 with choroidal osteoma from one community-based retina practice.

INTERVENTION

Laser ablation of subretinal neovascularization in two cases and focal laser treatment of retinal pigment epithelial leaks in one case.

METHODS

Photographs, fluorescein and indocyanine green angiograms, and clinical records were analyzed.

MAIN OUTCOME MEASURES

Demographic variables, visual acuity, complications of laser treatment, growth of lesions, and associated funduscopic changes.

RESULTS

Choroidal osteoma from a community setting is more frequently asymptomatic (5/11 cases; 45%) than in previously reported university series, is usually initially misdiagnosed, and is not rare. Light-intensity focal laser photocoagulation for serous retinal detachment unaccompanied by subretinal neovascularization can resolve fluid (1/11 cases; 9%). Laser ablation of secondary subretinal neovascularization stimulates rapid choroidal osteoma vascular remodeling (2/11 cases; 18%) and can cause retina-osteoma venous and arterial anastomoses (1/11 cases; 9%). Spontaneous choroidal hemorrhage unaccompanied by subretinal neovascularization can occur with confinement to the osteoma borders (1/11 cases; 9%). Association of choroidal osteoma with retinitis pigmentosa is reported.

CONCLUSIONS

These data on choroidal osteoma natural history and treatment help clinicians managing these lesions. In the community, a higher index of suspicion for choroidal osteoma is warranted.