45 year old female with decreased vision in left eye.

A 45-year-female presented with decreased vision in the left eye.

Questions

What do you see on the Fundus Photo?

Describe the findings on ultrasonography [Figure 1b] and optical coherence tomography (OCT) [Figure 1c and d]?

Figure 1

(Left eye at presentation) (a) fundus photograph (b) ultrasonography (c) spectral domain optical coherence tomography (d) spectral domain optical coherence tomography horizontal scan

What is the differential diagnosis? What features help to arrive at the most likely diagnosis?

Which type of laser is usually used for treatment

Describe the findings on ultrasonography and OCT after laser treatment.

Answers

Fundus examination of the left eye showed an orange colored choroidal mass with subretinal fluid involving 2 quadrants of the retina and involving the macula [Figure 1a]

B-scan ultrasonography [Figure 1b] shows a choroidal mass lesion. The choroidal lesion measured 9.95 mm at the base and 4.66 mm in thickness. Spectral domain (SD) OCT shows normal vitreoretinal interface, elevated foveal contour, fluid in the intraretinal layer with subfoveal neurosensory detachment, and normal retinal pigment epithelium [Figure 1c]. A horizontal line scan passing through the tumor showed hyporeflective cystic spaces over the tumor area with elevated retinal pigment epithelium [Figure 1d]

The differential diagnosis could be posterior scleritis, choroidal osteoma, and choroidal granuloma. During fundus examination, the circumscribed choroidal hemangioma (CCH) usually appears as an orange-red dome-shaped mass. In ultrasonography, it appears as a dome-shaped with medium to high reflectivity and with acoustic solidity

With informed written consent, transpupillary thermotherapy (TTT) laser was applied with a diode red laser. After the TTT, the left eye visual acuity was 20/125, and near vision was N12

On examination of the fundus, there was a scar in the base of the tumor [Figure 2a]. A repeat ultrasound showed shrinkage of the tumor size [Figure 2b]. SD-OCT (Carl Zeiss, Cirrus, Germany) showed normal foveal contour, no intraretinal cyst, negligible subfoveal fluid, elevated retinal pigment epithelium [Figure 2c], and resolved fluid over the tumor area [Figure 2d].

Figure 2

(Left eye following transpupillary thermotherapy) (a) fundus photograph (b) ultrasonography (c) spectral domain optical coherence tomography (d) spectral domain optical coherence tomography horizontal scan

Discussion

Choroidal hemangiomas are vascular hamartomas usually of two types, diffuse or circumscribed. It is generally believed that the tumor is present at birth or develops by early adulthood. A CCH should be treated as early as possible because it can cause cystoid macular edema, macular exudative retinal detachment, and chorioretinal atrophy which can lead to visual loss.[12]

On fundus examination, the CCH usually appears as an orange-red dome-shaped mass. In ultrasonography, it appears as a dome-shaped with medium to high reflectivity and with acoustic solidity.[2]

Optimal treatment of CCH needs very careful documentation of intraretinal and subretinal fluid. While the gross fluid can be detected by fundus examination and ultrasonography, currently, high definition OCT is the only instrument that can detect and document the subtle changes. Our case demonstrates that if we had relied on ultrasonography only, we might have stopped the treatment after first sitting itself. SD-OCT showed a fine pocket of fluid after the first treatment, and that allowed us to retreat. The patient did not have intraretinal fluid after the second treatment. Thus, SD-OCT can be an excellent tool to follow-up titrate thermotherapy for lesions such as choroidal hemangiomas.

In conclusion, SD-OCT is an advanced technique with which we can identify the minute changes in the retina. In this case, we elaborate the change in the retinal structure before and after treatment. It aids in determining the visual outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.