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CITY GROUND MEETING February 2008

Case presentation Case presentation p

Done by : Done by : Kadejah .Y. Al Kadejah .Y. Al-Attas Attas Kadejah .Y. Al Kadejah .Y. Al Attas Attas R2 R2

History History History History

34 year

34 year-

• old lady who presented to the ER
• ld lady who presented to the ER

complaining of distortion of vision in the left eye complaining of distortion of vision in the left eye f d for for two two days. days. Hi t f d l d d bl k t i Hi t f d l d d bl k t i

History of gradual decrease and black spots in

History of gradual decrease and black spots in her central vision in the left eye for more that two her central vision in the left eye for more that two years. years. yea s yea s

History of thyroid gland problem.

History of thyroid gland problem. y y g p y y g p

Examination Examination Examination Examination

VA

VA OD OD 20 20/ /40 40, PH , PH 20 20/ /25 25 OS OS 20 20/ /300 300, PH , PH 20 20/ /200 200

IOP

OD IOP OD 13 13 mmHg mmHg

IOP OD

IOP OD 13 13 mmHg mmHg OS OS 12 12 mmHg mmHg

Right eye examination within normal limits.

Right eye examination within normal limits.

Left eye examination:

Left eye examination:

Left eye examination:

Left eye examination: A/S within normal limits. A/S within normal limits. fundus examination. fundus examination.

FUNDUS EXAMINATION FUNDUS EXAMINATION FUNDUS EXAMINATION FUNDUS EXAMINATION

shows lesion at the macular

shows lesion at the macular

shows lesion at the macular

shows lesion at the macular area which is orange in color with well area which is orange in color with well-

• defined border and adjacent grayish

defined border and adjacent grayish defined border and adjacent grayish defined border and adjacent grayish subretinal membrane surrounded by subretinal membrane surrounded by some blood some blood some blood some blood

Differential Diagnoses Differential Diagnoses

Amelanotic Choroidal Melanoma

Amelanotic Choroidal Melanoma

Amelanotic Choroidal Melanoma

Amelanotic Choroidal Melanoma

Amelanotic Choroidal Nevus

Amelanotic Choroidal Nevus Ch id l t Ch id l t

Choroidal osteoma

Choroidal osteoma

Choroidal Hemangioma

Choroidal Hemangioma

Metastatic Carcinoma

Metastatic Carcinoma

Organized Submacular Hemorrhage

Organized Submacular Hemorrhage

Organized Submacular Hemorrhage

Organized Submacular Hemorrhage

Investigation Investigation Investigation Investigation

FFA

FFA:

shows diffuse mottled pattern of hyperfluorescence shows diffuse mottled pattern of hyperfluorescence during the late phase and shows classical during the late phase and shows classical CNVM with early hyperfluorescence and late CNVM with early hyperfluorescence and late leakage leakage leakage. leakage.

Cont Cont Cont. Cont.

B-scan: scan: B-scan: scan:

shows very dense shows very dense highly reflective lesion. highly reflective lesion. g y g y

A-scan: scan: A-scan: scan:

Shows calcified lesion. Shows calcified lesion.

Diagnosis Diagnosis Diagnosis Diagnosis

Diagnosis Diagnosis Diagnosis Diagnosis

Choroidal osteoma with secondary CNVM, OS Choroidal osteoma with secondary CNVM, OS

Treatment Treatment Treatment Treatment

Patient underwent intravitreal injection of Patient underwent intravitreal injection of Patient underwent intravitreal injection of Patient underwent intravitreal injection of Avastin Avastin 1.

.25 25mg/ mg/0 0. .05 05ml ml, OS

, OS

Choroidal Osteoma Choroidal Osteoma

choroidal osseous choristoma choroidal osseous choristoma

Definition: Definition: Definition: Definition: Acquired benign bony tumor. Acquired benign bony tumor. Epidemiology: Epidemiology:

Rare Rare Second decade Second decade 90 90% female (typically affects healthy young women) % female (typically affects healthy young women) Occasionally, familial cases have been reported.* Occasionally, familial cases have been reported.* y, p y, p

*Cunha SL. Osseous choristoma of the choroid. A familial disease. Arch *Cunha SL. Osseous choristoma of the choroid. A familial disease. Arch Ophthalmology. Ophthalmology.1984 1984; ; 102 102: :1052 1052-4

Ocular Manifestation: Ocular Manifestation:

Painless progressive loss of vision over several

Painless progressive loss of vision over several p g p g months or years or abrupt recent blurring of months or years or abrupt recent blurring of central vision. central vision.

80

80% of patients have % of patients have 20 20/ /30 30 vision or better at vision or better at

• presentation. Visual loss may be gradual or
• presentation. Visual loss may be gradual or

t d t RPE d ti CNVM t d t RPE d ti CNVM acute due to RPE degeneration or CNVM. acute due to RPE degeneration or CNVM.

The typical choroidal osteoma appears as

The typical choroidal osteoma appears as ll i h t l i ll ll i h t l i ll d fi d d fi d a yellowish to orange lesion, well a yellowish to orange lesion, well-defined, defined, juxtapapillary , involves one eye only in juxtapapillary , involves one eye only in 70 70 80% 80% f d b th i f d b th i 20 20 70 70-80% 80% of cases and both eyes in

• f cases and both eyes in 20

20- 30%. 30%.

The surface of the tumor may be relatively flat.

The surface of the tumor may be relatively flat.

If the lesion involves the macula, the visual

If the lesion involves the macula, the visual acuity can be impaired on the basis of acuity can be impaired on the basis of degeneration of the overlying RPE and sensory degeneration of the overlying RPE and sensory retina. retina.

In other cases a CNVM arises from the inner

In other cases a CNVM arises from the inner

In other cases, a CNVM arises from the inner

In other cases, a CNVM arises from the inner surface of the lesion which may produce surface of the lesion which may produce macular retinal detachment that result in loss of macular retinal detachment that result in loss of vision. vision.

Growth is seen in

Growth is seen in 40% 40% of cases with long

• f cases with long-
• term

term f ll f ll follow follow-

• up.

up.

Complications: Complications: Complications: Complications:

Secondary choroidal revascularization is

Secondary choroidal revascularization is

Secondary choroidal revascularization is

Secondary choroidal revascularization is common ( common (33% 33% of eyes with choroidal

• f eyes with choroidal
• steoma may develop CNVM )& responds
• steoma may develop CNVM )& responds
• steoma may develop CNVM )& responds
• steoma may develop CNVM )& responds

poorly to laser photocoagulation. poorly to laser photocoagulation.

sub

sub retinal fluid and sub retinal fluid and sub retinal retinal

sub

sub-retinal fluid, and sub retinal fluid, and sub-retinal retinal hemorrhages. hemorrhages.

Diagnosis: Diagnosis: Diagnosis: Diagnosis:

Because choroidal Because choroidal Because choroidal Because choroidal

• steomas are composed
• steomas are composed
• f dense bone, they
• f dense bone, they

appear as highly appear as highly reflective plate reflective plate-

• like

like lesions that shadow the lesions that shadow the lesions that shadow the lesions that shadow the

• rbit on B
• rbit on B-
• scan.

scan.

In CT In CT-

• scan, plate

scan, plate-

• like

like thickening of the posterior thickening of the posterior

• cular wall.
• cular wall.

Histology :

Histology : Mature bone with Mature bone with interconnecting marrow spaces Lesion is interconnecting marrow spaces Lesion is interconnecting marrow spaces. Lesion is interconnecting marrow spaces. Lesion is sharply demarcated form choroid. sharply demarcated form choroid.

Systemic Associations: Systemic Associations:

Occasional patients with choroidal osteoma have Occasional patients with choroidal osteoma have Occasional patients with choroidal osteoma have Occasional patients with choroidal osteoma have been found to have been found to have hyperparathyroidism hyperparathyroidism with with secondary alterations of the secondary alterations of the serum Calcium serum Calcium secondary alterations of the secondary alterations of the serum Calcium serum Calcium and and phosphorus phosphorus levels levels.

.

Treatment: Treatment: Treatment: Treatment:

Observation, unless secondary CNVM

Observation, unless secondary CNVM developed. developed.

Malignant transformation has not been reported.

Malignant transformation has not been reported.

Browning DJ, Fraser CM 2005 Browning DJ, Fraser CM 2005 :

They reviewed the clinical charts, photographs and They reviewed the clinical charts, photographs and fluorescein angiograms of 115 eyes of 96 fluorescein angiograms of 115 eyes of 96 patients with peripapillary subretinal CNVM over patients with peripapillary subretinal CNVM over patients with peripapillary subretinal CNVM over patients with peripapillary subretinal CNVM over 18 years, and they found that 1.7%(2 eyes) of 18 years, and they found that 1.7%(2 eyes) of CNVM caused by choroidal osteoma. CNVM caused by choroidal osteoma.

Browning DJ, Fraser CM. Ocular conditions associated with peripapillary subretinal Browning DJ, Fraser CM. Ocular conditions associated with peripapillary subretinal neovascularization, their relative frequencies, and associated outcomes. Ophthalmology. 2005 neovascularization, their relative frequencies, and associated outcomes. Ophthalmology. 2005 j 112(6) 10 4 j 112(6) 10 4 61 61 jun; 112(6):1054 jun; 112(6):1054-61 61.

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