Photodynamic therapy of circumscribed choroidal hemangioma

Abstract

Purpose To evaluate the safety and effectiveness of photodynamic therapy (PDT) in the treatment of symptomatic circumscribed choroidal hemangiomas (CCH) of the posterior pole. Design Prospective, consecutive, noncomparative case series. Participants Ten eyes of 10 patients (six males and four females; age range, 38–64 years) reporting visual impairment caused by intraocular CCH. Follow-up was 7 to 16 months. Methods Photodynamic therapy was applied by Zeiss laser (Visulas 6905, Carl Zeiss-Meditech AG, Jeud Germany) emitting a light at 689 nm for photosensitization and by using verteporfin (Visudyne; Novartis Ophthalmics AG, Basel, Switzerland) at a dose of 6 mg/m 2 body surface administered intravenously before treatment. The diameter of the treatment spot was calculated on early frames of pretreatment indocyanine green angiography; the maximum treatment spot diameter was 6000 μm using a Mainster wide-field lens (Ocular Instruments Inc., Bellevue, WA USA). In the case of peripapillary CCH, the laser spot was applied at a distance of 200 μm from the optic disc edge. A laser beam was applied to the retina 15 minutes after the start of the infusion. Two different treatment procedures were used according to the height of the lesion. A radiant exposure of 100 J/cm 2 with an exposure time of 186 seconds was applied to lesions larger than 2 mm. For lesions smaller than 2 mm, a radiant exposure of 75 J/cm 2 with an exposure time of 125 seconds was used. Main outcome measures Visual outcomes, pretreatment findings, and final findings were evaluated using biomicroscopy, fluorescein angiography (FA), indocyanine green angiography (ICGA), and ultrasound. Results After a follow-up of 7 to 16 months, FA and ICGA verified the nonperfusion of the vascular channels of the tumor in the treated areas. No retinal pigment epithelium (RPE) changes were observed in the patients who had undergone two PDT treatments, whereas minimal alterations were detected in two of the four patients who had undergone three treatment sessions. Angiographic cystoid macular edema and exudative macular detachment had completely regressed in all cases. Minimal intraretinal edema was observed on the FA frames in two cases. Ultrasound examination found no measurable tumor height in six (60%) cases and a marked reduction in the remaining four cases, even after one treatment (post treatment tumor height range, 0.86–1.82 mm). An improvement in visual acuity (one to six lines on the Early Treatment for Diabetic Retinopathy Study chart) was observed in all the cases. In four cases, the visual acuity returned to 20/20, of which three were extrafoveal and one was subfoveal with visual impairment caused by secondary exudative macular detachment without significant RPE alterations. Also in longstanding subfoveal cases, a marked visual acuity improvement was detected resulting from the disappearance of subretinal or intraretinal fluid, even if functional results were limited by pre-existing RPE alterations. In all cases no damage to retinal vessels was observed. Conclusions Photodynamic therapy is a minimally invasive but effective method of treatment for CCH and may be considered as a treatment of choice, especially in patients with foveal location of the tumor. Because of its safety and repeatability, this technique can be used to treat frequent recurrences of the tumor.