Atypical case of choroidal osteoma associated to polypoidal choroidal vasculopathy and preretinal neovascular membrane

PURPOSE

To report a very rare and atypical case of an elderly Caucasian female patient who developed perilesional multiple polypoidal choroidal vasculopathy (PCV) as a probable complication of choroidal osteoma (CO), associated to preretinal neovascular membrane overlying the lesion.

METHODS

Observational case report.

CASE OBSERVATION

A 60-year-old Caucasian woman presented with blurred vision in her right eye (RE). Fundus examination revealed a round white-yellowish calcified deep lesion in the juxta-papillary superior area, measuring 4 disc-diameters, with well-defined scalloped margins and an irregular surface. B-scan ultrasonography and orbital tomography confirmed the diagnosis of choroidal osteoma (CO). Further investigation with multimodal imaging including infracyanine green angiography, fluorescein angiography, swept source optical coherence tomography and angiography highlighted the presence of multiple aneurysmal choroidal dilations around the CO, corresponding to PCV. We also noted the presence of a preretinal neovascular membrane overlying the CO. The patient was monitored with regular follow-up since no signs of activity were detected on multimodal imaging.

CONCLUSION

Our case report represents an exceptional and atypical association between pre-retinal neovascularization, PCV and choroidal osteoma. While the mechanisms underlying the development of PCV and pre-retinal neovascularization in the setting of CO are not well understood, it is imperative for ophthalmologists to recognize this association as a potential cause of sudden vision loss in patients with CO, and to consider appropriate diagnostic and management strategies.

[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.

Complications, treatments, and visual prognosis of choroidal osteomas

PURPOSE

This study aims to report complications, treatments, and visual prognosis of choroidal osteoma.

METHODS

We retrospectively reviewed electronic medical records and multimodal images of 41 patients with choroidal osteoma.

RESULTS

Visually significant complications included choroidal neovascularization (CNV) in 21 (47.7%) eyes and subretinal fluid (SRF) without CNV in 14 (31.8%) eyes. The most common treatment was intravitreal anti-vascular endothelial growth factor (VEGF) injection: 13 (61.9%) eyes with CNV received an average of 6.3 injections, and 6 (42.9%) eyes with SRF but without CNV received 1.8 injections. As the first-line treatment, intravitreal anti-VEGF injection induced complete or partial remission in 93.4% of eyes with CNV and 57.1% of eyes with SRF. The probability of legally low vision estimated at 3 and at 5 years was 29.1% and 34.2%, respectively. The presence of CNV and outer retinal tubulation (ORT) was independent risk factors for vision loss (adjusted odds ratio, 8.08 and 6.94, respectively).

CONCLUSIONS

The development of CNV and ORT was strong risk factors for visual impairment. Due to the frequent recurrence of complications and poor visual prognosis, regular check-ups and appropriate treatment choices are warranted.

Peculiar presentation of bilateral choroidal osteoma in a child

Report of a presentation of bilateral choroidal osteoma without neovascularization in a child following a school screening. Diagnosis was based on funduscopy, optical coherence tomography and B-scan ultrasonography. The child was followed regularly with cycloplegic refraction, funduscopy, macular SD-OCT and EDI-SD-OCT. Fluorescein angiography and OCT-angiography will be performed if necessary.

PURPOSE

To report a peculiar presentation of bilateral choroidal osteoma in a very young child.

METHODS

Case report.

RESULTS

During a school screening, a 4-year-old girl was detected with anisometropia as the first sign of a bilateral choroidal osteoma. The diagnosis was based on funduscopy, optical coherence tomography and B-scan ultrasonography.

CONCLUSION

Choroidal osteomas are rare benign tumors that can lead to severe visual loss due to progression or complications. They are found mostly in young adults, but in our case, the refractive screening allowed an early diagnosis despite the lack of visual symptoms.

Novel OCT findings in choroidal osteoma: brief report

The aim of this article is to report the presence of choroidal loculation of fluid and choroidal cavern in a case of choroidal osteoma, previously undescribed in this disease.

Secondary choroidal neovascularization due to choroidal osteoma after 9 years follow-up

BACKGROUND

Choroidal osteoma is a benign intraocular tumor that can increase risk of developing choroidal neovascularization. The visual prognosis is influenced by the tumor location, decalcification status, overlying RPE atrophy, presence of choroidal neovascularization, persistence of subretinal fluid and occurrence of subretinal hemorrhages.

CASE PRESENTATION

The authors present a 40-year-old woman diagnosed with choroidal osteoma of the right eye. Her best corrected visual acuity was 12/20 but decreased to 5/20 due to secondary choroidal neovascularization after 8 years follow up. Fundus examination revealed an enlarged choroidal osteoma in most margins at posterior pole with schistose hemorrhage beside macula. Optical coherence tomography angiography revealed unique features in the vascular changes of choroidal neovascularization in choroidal osteoma in the outer retinal layer and choroid capillary layers, and subretinal neovascularization. Indocyanine green fluorescence angiography showed there was hypo-fluorescence at the peripapillary with faint hyper-fluorescence at the macular, corresponding to the location on the fundus photograph. The patient received 3 injections of intravitreal ranibizumab. After 1 year follow up, her visual acuity of the right eye was 18/20 and the CNV had regressed.

CONCLUSIONS

We present the findings and treatment of a case of choroidal osteoma with secondary choroidal neovascularization. Optical coherence tomography angiography combined with FFA and ICGA is used to analysis the characteristics of secondary choroidal neovascularization. Optical coherence tomography angiography can reveal some unique characteristics in the vascular changes compared to fundus fluorescein angiography.

Photodynamic therapy for macular choroidal osteoma

PURPOSE

To report a case of macular choroidal osteoma treated with photodynamic therapy.

OBSERVATIONS

A 34-years old woman with decreased visual acuity in her left eye came to our observation for assessment of an amelanotic choroidal tumor in the left eye. On the basis of ophthalmoscopic and echographic features the tumor was diagnosed as choroidal osteoma. Imaging examination revealed subretinal fluid involving the foveal area associated with alterations of outer neuroepithelial layers and photoreceptors without evidence of choroidal neovascularization. Foveal sparing standard fluence rate photodynamic therapy was performed. After treatment, subretinal fluid reabsorption and visual acuity recovery was noted with progressive restoration of foveal architecture. Due to the relapse of fluid and visual impairment, 1 year after treatment, a second PDT session was made using the same parameters and protocol of treatment. Despite a complete subretinal fluid reabsorption and visual acuity recovery the second treatment was complicated by the development of subretinal fibrosis.

CONCLUSIONS

PDT is effective to induce subretinal fluid reabsorption and visual recovery in choroidal osteoma located in the macular area. However, the risk of possible complications related to the treatment have to be considered.

Novel observations in choroidal osteoma by multispectral imaging: a pilot case series

PURPOSE

To identify novel tumor-specific features of ossification by using multispectral imaging (MSI) in patients diagnosed with choroidal osteoma.

METHODS

Six eyes of 5 patients previously diagnosed with choroidal osteoma by ocular ultrasonography and orbital computerized tomography were observed with multispectral imaging (MSI). Traditional multimodal imaging, including color fundus photograph (CFP) and enhanced depth-imaging-optical coherence tomography (EDI-OCT), fundus autofluorescence (FAF), indocyanine green angiography/fundus fluorescein angiography (ICGA/FFA), was performed. Osseous features detected by MSI such as calcification and decalcification were characterized and compared with other imaging modalities.

RESULTS

In all 3 eyes with calcified choroidal osteoma (100%), MSI featured by the homogeneous reflectance in 550 nm but the beehive appearance in 600-680 nm and homogenous hyper-reflectance in 780-850 nm', indicating the compact bone in the outer layers and bone trabecula in the middle layer (Sandwich sign). The pigmentary change showed high agreement between MSI and FAF. In other 3 eyes with extensive decalcification, MSI was able to differentiate the inactive portion of the osteoma from the decalcified area. The inactive portion was characterized by geographic hyper-reflective islands with higher reflectivity border (floating island sign). Decalcified portion was featured by increased definition and reflectivity from osteoma. Partial decalcification and total decalcification can be differentiated in one decalcifying eye (33.3%). MSI revealed better the presence and border of the osteoma compared with FFA, FAF and MC (100%) in all six eyes in our study.

CONCLUSIONS

MSI presented characteristic osseous-related features of choroidal osteoma, providing clear evidence for differentiating osteoblastic and osteoclastic regions and noncalcifying regions. It can contribute to en-face visualization of choroidal osteomas at different stages, providing new insight into the spectrum behavior of CO.

Spontaneous resolution of serous retinal detachment caused by choroidal mass after a first trimester abortion

Pregnancy-related ocular diseases develop mostly in the third trimester of pregnancy. Here, we describe a case of a pregnant woman with a choroidal mass that caused a serous retinal detachment during the first trimester of pregnancy. The patient's condition resolved spontaneously after an abortion.

Focal choroidal excavation and pitchfork sign in choroidal neovascularisation associated with choroidal osteoma

PURPOSE

To describe a complex case of choroidal osteoma complicated by choroidal neovascularisation and focal choroidal excavation and presence of pitchfork sign.

METHODS

A young female patient with confirmed diagnosis of choroidal osteoma was followed up for 5 years. Multimodal imaging including optical coherence tomography and fluorescein angiography (Spectralis HRA + OCT; Heidelberg Engineering, Heidelberg, Germany) was performed.

RESULTS

Optical coherence tomography showed the presence of a unilateral choroidal osteoma in the first visit which was later followed by the appearance of focal choroidal excavation. After 3 years, choroidal neovascularisation developed in choroidal osteoma area, with subretinal fluid, subretinal hyper-reflective material, hyper-reflective foci and pitchfork sign. Decalcification of the tumour was not noted in this patient. Treatment with one intravitreal injection of Aflibercept resulted in complete disappearance of subretinal fluid, subretinal hyper-reflective material, pitchfork sign and decreased hyper-reflective foci.

CONCLUSION

Inflammatory response can be a propulsive element in the development of focal choroidal excavation and choroidal neovascularisation in choroidal osteoma patients.

Bilateral choroidal osteoma associated with langerhans cell histiocytosis, a coincidence?

Purpose

To describe a case of bilateral choroidal osteoma (CO) in a patient with a history of langerhans cell histiocytosis (LCH).

Methods

A 24-year-old man complaining of gradually decreasing visual acuity in both eyes is presented. He had a history of lymphadenopathy, respiratory symptoms, and pathology-proven diagnosis of LCH.

Results

Ophthalmic clinical and imaging studies revealed bilateral CO.

Conclusion

In this patient, we suggest a possible relationship between LCH and CO.

Multicolor imaging in choroidal osteomas

Background

To describe the multicolour (MC) imaging characteristics associated with choroidal osteomas (CO) and their secondary complications.

Methods

Retrospective descriptive case series of eleven eyes of ten patients with CO. Findings of multicolour imaging were correlated with visual acuity, clinical features, lesion characteristics and findings from other imaging modalities.

Results

Infrared reflectance (IR) images showed calcified CO lesions as hyporeflectance (dark) areas while decalcified lesions were seen as iso reflectance (normal) areas. Overlying RPE atrophy on IR were seen as white areas. MC images showed color variations depending upon the reflectivity of the tumour material tumour and retinal pigment epithelial (RPE) atrophy. Green color was noted in calcified CO tumour while decalcified CO tumour showed no color change. RPE atrophy were seen as bright orange areas. Green and blue reflectance images were not able to pick the choroidal osteoma lesion. Other changes secondary to CO like presence of choroidal neovascular membrane, hemorrhage and/or fluid in the retinal layers were identified on green and blue reflectance images.

Conclusion

MC imaging is a useful tool in our arsenal of existing imaging modalities in the assessment of CO and its secondary changes. Change in reflectance of the IR and MC images can be used as an indicator to assess the extent of tumour decalcification and its secondary changes and therefore, can aid in prognostication in the same. It has the potential to replace color fundus photography in documentation and follow up of patients with CO.

Multimodal imaging in choroidal osteoma

Purpose

To describe characteristics of choroidal osteomas (CO), using ocular ultrasound, fluorescein angiography, ultra-widefield retinal imaging, ultra-widefield autofluorescence, optical coherence tomography, enhanced-depth-imaging OCT, and OCT angiography (OCT-A).

Methods

Retrospective, observational case series study. Clinical records from patients with diagnosis of CO who underwent complete imaging evaluation were analyzed.

Results

Sixteen eyes from 11 patients were included. Mean patient age was 33.4 years (range 20–61), 72.7% were female, 100% were Hispanic, and 54.5% had unilateral CO. Median visual acuity was 20/150 (range 20/20–2000). CO was completely calcified in 25%, partially decalcified in 50%, and decalcified in 25%. Other features included choroidal neovascularization (18.75%), focal choroidal excavation (12.5%), choroidal depression associated to decalcification (18.75%), thinning of outer retina and photoreceptor layers over decalcified tumor (75%). Decreased fluorescence on FAF was observed in decalcified regions while relatively preserved fluorescence was observed in calcified regions.

Conclusions

Nowadays, diagnostic tests provide important information about each stage of choroidal osteoma. Progressive decalcification of the tumor might have a common pathogenic role for development of FCE or choroidal depression. OCT-A/FA proved to be valuable tools for detection of CNV in patients with CO.

Choroidal osteoma with choroidal excavation and associated neovascular membrane: An OCT-angiography study

CLINICAL CASE

A case is presented of a unilateral choroidal osteoma with choroidal excavation and associated neovascular membrane that was studied using OCT-angiography. The OCT and OCT-angiography revealed an area of choroidal excavation and an active neovascular membrane. Three doses of aflibercept were administered to the patient, which stabilised the neovascularisation.

DISCUSSION

OCT-angiography was used to analyse the morphology of the superficial vascular network of the osteoma, as well as to monitor the evolution of the neovascular membrane.

Choroidal osteoma in a preterm infant

Choroidal osteoma (CO) is a rare, benign, and usually unilateral intraocular tumor composed of mature bone affecting the choroid. It appears as slightly elevated, yellowish-white, or orange choroidal mass with well-defined borders. It is commonly encountered in young female adults. Here, we report findings of a 4-week-old premature baby with CO in her left eye which was detected during a routine examination for "retinopathy of prematurity." We believe that this case is the youngest patient reported with CO which showing that this pathology can be encountered even in a newborn.

Choroidal Osteoma and Secondary Choroidal Neovascularization Treated with Ranibizumab

A 47-year-old female patient presented with a complaint of decreased vision in the right eye. Her visual acuity was 0.16 in the right eye and 1.0 in the left eye. Fundus examination revealed a slightly elevated, yellowish-white lesion with regular borders at the macula of the right eye. Early and late hyperfluorescence related with choroidal neovascularization (CNV) was detected in the right eye on fundus fluorescein angiography. B-scan ultrasonography revealed a hyperechoic choroidal lesion with acoustic shadowing. The lesion was diagnosed as choroidal osteoma. The patient received 3 injections of intravitreal ranibizumab. After 4 months, the visual acuity of the right eye was 0.9 and the CNV had regressed. Follow-up at about 7 months revealed reduced visual acuity in the right eye with an increase in subretinal fluid. An additional ranibizumab injection was administered. In this case report, we discuss the findings and treatment of a rare case of choroidal osteoma with secondary CNV.

Intravitreal ranibizumab for treatment of choroidal neovascularization secondary to a bilateral choroidal osteoma

Purpose

Choroidal osteomas are benign intraocular tumors that classically present in females. Despite their benign nature, significant visual acuity loss can occur due to retinal pigment epithelium degeneration. We report an unusual case of bilateral choroidal osteoma in a young boy.

Observation

A 16 year old boy presented to the Aga Khan University Hospital with a history of painless, bilateral deteriorating vision over past few months. Examination showed best corrected visual acuity as 20/200 in the right eye and 20/400 in the left eye. Funduscopy revealed a well-defined lesion in the juxtafoveal region of both eyes. A diagnosis of (bilateral) choroidal osteoma was subsequently made on the basis of optical coherence tomography, fundus fluorescein angiography, Indocyanine green and B-scan ultrasonography. The presence of choroidal neovascularization with sub retinal fluid was also established on OCT. The patient was treated with three intravitreal Ranizumab injections. At the follow up visit, vision had improved to 20/50 in the right eye and 20/200 in the left. Sub retinal fluid had also resolved.

Conclusions

and importance: Intravitreal Ranizumab may be an effective alternative in the management of choroidal neovascularization secondary to choroidal osteoma.

Bone Remodeling in Choroidal Osteoma Monitored by Fundus Photography and Spectral-Domain Optical Coherence Tomography

Choroidal osteoma is a benign ossifying tumor of the choroid, consisting of mature bone tissue. It has been described to enlarge and evolve at varying rates over time. Here, we report and quantify the progression of a unilateral choroidal osteoma in a 7-year-old boy by fundus photography, and document tumor remodeling by spectral domain optical coherence tomography images.

Swept-source optical coherence tomographic findings of choroidal osteoma

Purpose

To report the morphologic features of a choroidal osteoma using swept-source optical coherence tomography (SS-OCT) and fundus autofluorescence (FAF).

Methods

Two eyes of two cases with a choroidal osteoma were studied using SS-OCT and FAF.

Results

The location of the tumor was circumpapillary without macular involvement in case 1 and juxtapapillary with macular involvement in case 2. Both cases had a mixture of calcified and decalcified areas, and a concomitant choroidal neovascularization was found in case 2. The FAF images showed decreased autofluorescence in the central decalcified regions and relatively preserved fluorescence in marginal calcified regions in both cases. SS-OCT revealed a normal inner retina and an abnormal outer retina in both cases, and subretinal fluid in case 2. The calcified regions appeared sponge-like and were multilayered in case 2. A lamellar reflective pattern was observed in the decalcified regions in case 1, and hyperreflective mound-like areas were observed in both cases. SS-OCT demonstrated hyperreflective areas above Bruch's membrane accompanied by disruption of Bruch's membrane in case 1. The chorioscleral border was visible in both cases.

Conclusions

The FAF pattern in the calcified and decalcified areas of the choroidal osteoma may correspond to the different stage of tumor evolution. The SS-OCT findings indicate that choroidal osteomas can have characteristic reflective patterns and alterations of the overlying retina.

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.

Long-Term Follow-Up of Intravitreal Ranibizumab for the Treatment of Choroidal Neovascularization due to Choroidal Osteoma

Choroidal osteoma is an uncommon benign osseous intraocular tumor that typically affects young adult women. Choroidal neovascularization (CNV) is one of the complications that can develop in eyes with choroidal osteoma. We present a case of CNV secondary to choroidal osteoma treated with intravitreal ranibizumab. A 57-year-old lady presented with painless loss of vision with a right-eye visual acuity of 20/800. Fundus examination showed a well-demarcated yellowish peripapillary choroidal osteoma with associated retinal and subretinal hemorrhage due to CNV. Three intravitreal ranibizumab injections at monthly intervals were given and her visual acuity improved to 20/30 following treatment. After 1.2 years of follow-up, the right eye visual acuity was maintained at 20/30 with no evidence of CNV recurrence. Our findings suggest that intravitreal ranibizumab may be an effective therapeutic option for treating CNV secondary to choroidal osteoma.