CITY GROUND MEETING February 2008 Case presentation Case presentation p Done by : Done by : Kadejah .Y. Al Kadejah .Y. Al-Attas Kadejah .Y. Al Kadejah .Y. Al Attas Attas Attas R2 R2
History History History History � 34 year 34 year- -old lady who presented to the ER old lady who presented to the ER complaining of distortion of vision in the left eye complaining of distortion of vision in the left eye for two f for two days. days. d � History of gradual decrease and black spots in Hi t Hi t History of gradual decrease and black spots in f f d d l d l d d bl d bl k k t i t i her central vision in the left eye for more that two her central vision in the left eye for more that two yea s years. yea s years. � History of thyroid gland problem. History of thyroid gland problem. y y y y g g p 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 IOP IOP OD 13 OD OD 13 13 mmHg 13 mmHg 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 � Choroidal osteoma Ch Choroidal osteoma Ch id l id l t t � 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: B-scan: scan: scan: shows very dense shows very dense highly reflective lesion. highly reflective lesion. g y g y
A-scan: A-scan: 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 1. Avastin ml , OS , OS .25 25mg/ mg/0 0. .05 05ml
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% female (typically affects healthy young women) 90 % female (typically affects healthy young women) Occasionally, familial cases have been reported.* Occasionally, familial cases have been reported.* y, y, p 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 p g 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 acute due to RPE degeneration or CNVM. acute due to RPE degeneration or CNVM. t t d d t t RPE d RPE d ti ti CNVM CNVM
� The typical choroidal osteoma appears as The typical choroidal osteoma appears as a yellowish to orange lesion, well-defined, a yellowish to orange lesion, well ll ll i h t i h t l l i i ll ll d fi d fi defined, d d juxtapapillary , involves one eye only in juxtapapillary , involves one eye only in 70 70 80% 70 70-80% 80% 80% of cases and both eyes in of cases and both eyes in 20 f f d b th d b th i i 20 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 of 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 of eyes with choroidal osteoma may develop CNVM )& responds osteoma may develop CNVM )& responds osteoma may develop CNVM )& responds osteoma may develop CNVM )& responds poorly to laser photocoagulation. poorly to laser photocoagulation. � sub � sub sub retinal fluid and sub sub-retinal fluid, and sub retinal fluid and sub retinal retinal fluid, and sub-retinal retinal retinal hemorrhages. hemorrhages.
Diagnosis: Diagnosis: Diagnosis: Diagnosis: Because choroidal Because choroidal Because choroidal Because choroidal osteomas are composed osteomas are composed of dense bone, they of 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 orbit on B orbit on B- -scan. scan.
In CT In CT- -scan, plate scan, plate- -like like thickening of the posterior thickening of the posterior ocular wall. ocular 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 secondary alterations of the secondary alterations of the serum Calcium serum Calcium serum Calcium levels . . and and phosphorus phosphorus 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.
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