Subretinal Mass Research Articles

Localizing polypoidal choroidal vasculopathy for laser treatment

75-year-old woman reporteddecreased vision and metamorp-hopsia in her right eye of 15 days’duration. Both eyes showed a visualacuity (VA) of 20⁄40 and normalanterior segments and intraocularpressure. Ophthalmoscopical examina-tion suggested a macular detachmentof the retinal pigment epithelium(RPE), but failed to disclose any hae-morrhages or exudates (Fig. 1). Theleft eye was entirely normal.Fluorescein angiography (FA) inthe right eye revealed a pooling of dyecorresponding to the serous RPEdetachment visible on fundus exam-ination (Fig. 2), and late-phase indo-cyanine green (ICG) angiographydemonstrated a prominent leakageinto the RPE, with no evidence ofchoroidal neovascularization.Six months later, the patient noted asudden decrease in vision in her righteye (VA 20⁄200). Funduscopy, per-formed 1 week later, demonstrated amacular serosanguineous RPE detach-ment (Fig. 3). While FA confirmed thefunduscopic findings (Fig. 4), opticalcoherence tomography (OCT) showed,in addition, a prominent orange subre-tinal mass protruding anteriorly, nextto the RPE detachment (Fig. 5). Inearly-phase ICG videoangiography,the mass corresponded to a typical,small vascular network with three poly-poidal structures, not detectable onFA, located inferiorly in the papilloma-cular area (Fig. 6). The polypoidal

Circumscribed choroidal hemangioma: A case report and review of the literature

Background Choroidal hemangioma is a rare, benign vascular ocular tumor that presents as either a circumscribed mass or as a diffuse variant. Circumscribed choroidal hemangiomas (CCH) resemble posterior segment lesions such as choroidal melanoma, choroidal metastases, central serous chorioretinopathy, or nonspecific retinal detachment. A circumscribed choroidal hemangioma often appears as a subtle red–orange mass or as a grayish lesion in the posterior choroid. In rare instances, CCH may be associated with subretinal fluid accumulation and retinal detachment. Case Report A 35-year-old Hispanic man presented for a routine eye examination and was observed to have a choroidal lesion in the posterior pole. The lesion is an elevated subretinal mass located superotemporal to the fovea in the right eye. A Humphery visual field 24-2 test found a scotoma corresponding to the location of the lesion. B-scan ultrasound confirmed a fairly dense and large lesion. A-scan showed low to medium internal reflectivity and an acoustically solid lesion. Because the patient was asymptomatic, management through observation was recommended. Conclusions Circumscribed choroidal hemangiomas must be adequately differentiated from other vascular tumors. A selective battery of diagnostic tests will facilitate the correct diagnosis. Management of CCH may depend on the character of the lesion and risks of ocular morbidity and vision loss.

Ocular Manifestation of Cat-Scratch Disease in HIV-Positive Patients

To characterize ocular manifestations of cat-scratch disease in HIV-positive patients. Retrospective case series study. Records and photography of patients with the diagnosis of cat-scratch disease and HIV were reviewed. From 2001 and 2004 three patients with cat-scratch disease and HIV were identified. All patients presented with subretinal mass associated with an abnormal vascular network. Fluorescein angiography revealed this abnormal vascular network more clearly. All patients were treated with antibiotics alone with good response. Subretinal mass associated with abnormal vascular network is characteristic of cat-scratch disease in HIV-positive patients. Fluorescein angiography is important to characterize this vascular pattern, and patients may benefit from systemic treatment.

Giant nodular posterior scleritis simulating choroidal melanoma

A 45-year-old woman, complaining of sudden visual loss in the right eye (best-corrected visual acuity: 17/200), was suspected of having a malignant melanoma of the choroid. Fundus examination revealed a massive pale-colored subretinal mass temporal to the fovea, with adjoining choroidal folds and exudative retinal detachment. Ultrasonography was suggestive of posterior scleritis. Systemic evaluation was unremarkable. The patient was treated with high-dose systemic corticosteroids. The mass lesion resolved completely, with visual recovery to 20/20. Posterior scleritis should be suspected when evaluating subretinal mass-lesions, even when large and without overt inflammation. Early treatment may improve the visual prognosis and avoid misdirected management, including enucleation.

Ring-Shaped Subretinal Fibrinous Exudate in Central Serous Chorioretinopathy

To clarify the pathologic changes of the ring-shaped, grayish white subretinal fibrinous exudate in central serous chorioretinopathy (CSC), we examined patients with fluorescein angiography (FA) and optical coherence tomography (OCT). Using OCT, we prospectively examined 13 consecutive patients (12 men, one woman) (13 eyes) with acute CSC. The fundi were scanned by OCT through the ring-shaped, grayish white lesion. FA showed focal dye leakage at the center of the ring-shaped, grayish white subretinal exudates. In the area of the exudates, OCT showed moderately or highly reflective masses bridging the neurosensory retina and the retinal pigment epithelium in all eyes. Because the area of the pellucid core of the ring-shaped exudate showed an optically clear space beneath the neurosensory retina, the subretinal reflective masses were separated on cross-sectional images in all 13 eyes. Pigment epithelium detachment was observed in the area of the grayish white lesion by OCT and FA in 7 of the 13 eyes. In eyes with a ring-shaped, grayish white exudate in CSC, OCT and FA findings indicate that the pellucid core of the exudate is the route of the exudative fluid from the choroid into the subretinal space. A surrounding grayish white lesion seems to be fibrinous exudate that has accumulated in the subretinal space.

Circumscribed Choroidal Hemangioma in a Chinese Patient Treated using Transpupillary Thermotherapy: A Case Report

We describe the first case of a Chinese patient with circumscribed choroidal hemangioma (CCH) effectively managed using transpupillary thermotherapy (TTT). A 57-year-old man had an elevated orange-red subretinal mass with a base of 5 x 5 mm superior to the optic disc, along with serous macular detachment in the left eye. Ultrasonography depicted a mass 3 mm thick with acoustic solidity and high internal reflectivity. Fluorescein angiography showed an area of hyperfluorescence in the prearterial phase and tumor staining in the late phase, consistent with a diagnosis of CCH. Therefore, TTT (spot size, 3 mm; exposure, 1 min) was performed with a diode laser, delivered through a slit-lamp biomicroscope. The laser power was first set at 300 mW and then increased in 50-mW increments, until test shots in the mid-peripheral retina outside the lesion produced a slightly grayish appearance in the irradiated area. The tumor was covered with four overlapping laser spots and subjected to an average beam power of 400 mW. Best-corrected visual acuity increased from 20/50 before treatment, to 20/20 3 months following one session of TTT. The lesion became atrophic and the subretinal fluid disappeared. Our experience shows that TTT can be an even more effective treatment strategy for CCH in Asians than in Caucasians. In Chinese patients, the power level of the diode laser should be lower than that used in Caucasians.

Subretinal Inflammatory Myofibroblastic Tumor: Clinicopathological Findings

To present a case of inflammatory myofibroblastic tumor which was manifested as an idiopathic subretinal mass without underlying pathology. The subretinal mass was surgically excised and evaluated histopathologically. Fluorescein angiography and optical coherence tomography were performed pre- and post-operatively. The mass was histologically composed of lymphoplasma cell infiltration and fibrous proliferation without microorganisms or malignant cells. Immunohistochemistry for smooth muscle actin revealed myofibroblasts as a major cellular component. Preoperative optical coherent tomography showed that the lesion was contiguous to the retina while inducing foveal detachment. Postoperatively, the fovea was attached with visual recovery, and the subretinal lesion did not recur during the follow up. Inflammatory myofibroblastic tumors may be included in the differential diagnoses of subretinal masses.

Subretinal Mass as a Presenting Sign of Posterior Scleritis: A Case Report

We report a case of an unusual clinical presentation of posterior scleritis. A 40-year-old woman suffered from sudden blurred vision in her left eye for 1 day. She had no systemic or autoimmune diseases. Fundus examination revealed a subretinal mass (10.5 x 6 mm in basal diameter) in the nasal-superior quadrant extending from the optic disc to the periphery. Overlying retinal striae were obvious. Optic disc hyperemia and mild edema were noted. Fluorescein angiography did not show dye leakage or tumor-feeding vessels. Ultrasonography showed high internal reflectivity of the subretinal mass and thickened sclera with T-sign. Under the impression of posterior scleritis, corticosteroids and nonsteroidal anti-inflammatory drugs were given orally and topically. After 4 weeks, the subretinal mass disappeared without any sequelae. The patient recovered full vision. This case suggests that posterior scleritis is among the differential diagnoses for a fundus mass. There has been no other similar report in Taiwan.

Magnetic resonance imaging characteristics of posterior scleritis mimicking choroidal mass

We present imaging findings in a case of posterior scleritis, which may mimic tumoral mass lesion resulting in unnecessary enucleation. Magnetic resonance imaging was remarkable for a subretinal mass hypointense on T2 and hyperintense on T1 weighted images. A peripheral rim of hypointensity was noteworthy, suggestive of sclerouveal thickening. There was an ill-defined area of increased T2 signal intensity adjacent to globe at the site of nodular lesion implying an inflammatory process. A linear contrast enhancement was seen within the bulbus oculi which may represent detached retina by exudation or displaced retina due to thickened sclera and choroidal layers. The CSF space around the optic nerve was enlarged.

Evaluation of central serous chorioretinopathy with optical coherence tomography

PURPOSE: To evaluate central serous chorioretinopathy with optical coherence tomography during the acute phase and after resolution of the acute phase. METHODS: In a prospective study, 23 consecutive eyes of 23 patients (19 men, four women; mean age ± SD, 46.0 ± 8.1 years; range, 29 to 60 years) with central serous chorioretinopathy were examined with optical coherence tomography during the acute phase and after resolution of the retinal detachment. After the initial examination, the patients were reexamined for 3 to 6 months (mean, 4.7 ± 1.1 months). Cross-sectional retinal images through the center of the fovea were obtained from all eyes by optical coherence tomography. The retinal thickness at the center of the fovea was measured. The difference between the retinal thickness during the acute phase and after resolution of the retinal detachment was statistically analyzed using the Wilcoxon test. We also examined a grayish-white lesion that corresponded to the leakage point in fluorescein angiography in four eyes. RESULTS: In the acute phase, neurosensory retina was thickened within the area of serous retinal detachment in all 23 eyes. The detached retina was thicker than the reattached retina after resolution of the retinal detachment in all eyes. The retinal thickness at the center of the fovea during the acute phase (range, 157 to 236 μm; mean ± SD, 196.9 ± 22.6 μm) was significantly thickened compared with that after resolution (range, 105 to 152 μm; mean ± SD, 124.8 ± 10.7 μm; P <.0001, Wilcoxon test). In the acute phase, areas of low reflectivity localized within the detached retina were observed in 18 of the 23 eyes. In the area of the grayish- white lesion, optical coherence tomography showed a moderately reflective mass bridging the detached neurosensory retina and retinal pigment epithelium in the four eyes; the outer layer of the detached retina was more highly reflective in these eyes. The retinal pigment epithelium was focally detached beneath the subretinal reflective mass in three of the four eyes. CONCLUSIONS: In all eyes studied, neurosensory retina was thickened within the area of serous retinal detachment in the acute phase of central serous chorioretinopathy. The grayish-white lesion seems to be a fibrinous exudate that accumulates in the subretinal space and infiltrates into the outer retina.

Optical coherence tomography of idiopathic polypoidal choroidal vasculopathy

PURPOSE: To document and study the cross-sectional structures of polypoidal elements using optical coherence tomography in eyes with idiopathic polypoidal choroidal vasculopathy. METHODS: Optical coherence tomography images of two eyes with idiopathic polypoidal choroidal vasculopathy were correlated with slit-lamp biomicroscopic findings, fundus photographs, fluorescein angiograms, and indocyanine green angiograms. RESULTS: Cross-sectional optical coherence tomographic images of retinochoroidal structures showed prominent anterior protrusion of the orange subretinal mass corresponding to the polypoidal structure in the indocyanine green angiogram. Hemorrhagic detachment of the retinal pigment epithelium was contiguous with the cone-shaped nodule beneath the retinal pigment epithelium in one eye, and an apparent discontinuity was observed in the highly reflective layer that delineates the polypoidal structure. CONCLUSIONS: Some of the polypoidal structures in eyes with idiopathic polypoidal choroidal vasculopathy are anteriorly protruding lesions in the inner choroid that may cause serosanguineous detachment of the retinal pigment epithelium through damage of the overlying Bruch membrane, retinal pigment epithelium, and the adhesion between them. Cross-sectional optical coherence tomographic images may increase understanding of the pathophysiology of idiopathic polypoidal choroidal vasculopathy.

Accidental Subretinal Injection of Triamcinolone Acetonide

Approximately one-third of the contents of a 1-ml, 40-mg ampule of triamcinolone acetonide was accidentally injected into the subretinal space of the left eye of a 30-year-old man with chronic uveitis. The manufacturer provided a list of the contents of the ampule. A large, white subretinal mass was seen in the superotemporal quadrant. In subsequent days, the medication was seen to migrate inferiorly. Visual acuity in the left eye was 20/400. Subretinal hemorrhage and mild atrophy of the retinal pigment epithelium and choroid were observed superotemporally. Visual acuity returned to 20/100 (preinjection level) in 1 week. Four months postinjection, the superotemporal atrophy was more severe; the inferotemporal medication was minimally visible without producing significant chorioretinal atrophy. The visual acuity remained at 20/100 until the patient underwent cataract extraction and intraocular lens implantation; his vision then improved to 20/40. Steroids, when not accompanied by harmful vehicle substances, may be well tolerated by ocular tissues.

Ultrasonic Evaluation of the Vitreous and Retina

Ultrasonic evaluation of the vitreous body augments and complements visual and clinical assessment in any condition in which some form of media opacity exists, eg, cornea, lens, hemorrhage, or subretinal mass. The appearance of the eye in hypotony, the presence of foreign material, the pattern of hemorrhage, and the presence of a detached retina or choroid are all identifiable and their diagnosis may be of critical importance to patient management. Patterns of diabetic retinopathy and ocular tumors are usually characteristic using conventional 10 MHz ultrasound. The use of Very High Frequency (VHF or UBM) ultrasound can identify ciliary body detachment or other retroiridal pathology, such as tumors and cysts.

AIDS-associated intraocular lymphoma causing primary retinal vasculitis

Background: There is an increasing association between ocular-central nervous system (CNS) lymphoma and the acquired immunodeficiency syndrome (AIDS). In this population, the disease generally occurs in a younger age group. The origin of these B-cell neoplasms remains unknown. Method: Case study of a 26-year-old AIDS patient with an incidental finding of localized retinal vasculitis and local vitritis. Disease progression and the failure of antiviral therapy led to early diagnostic vitrectomy with vitreal and retinal biopsy. Cerebrospinal fluid (CSF) evaluation, head magnetic resonance imaging (MRI), and brain biopsy were performed. Results: The diagnosis of ocular non-Hodgkin lymphoma was made by vitreous cytology. Serial sectioning of a retinal biopsy showed no retinal neoplastic infiltration, only perivascular inflammatory cells, CSF was normal. MRI showed multicentric brain mass lesions that enhanced with intravenous contrast. Brain biopsy revealed an immunoblastic, angiocentric, B-cell non-Hodgkin lymphoma. The patient died within two months, despite cerebral and ocular irradiation. Conclusions: The segmentally localized retinal vasculitis-vitritis and absence of retinal infiltration suggested early primary involvement of the vitreous. Coarse perivascular sheathing is characteristic of the mixed retinal vasculitis in this disease. The diagnosis of ocular-CNS lymphoma must be considered in patients with AIDS, however young, with unexplained posterior segment inflammatory disease or subretinal masses.

Choroidal osteoma: an atypical presentation

Choroidal osteomas are benign osseous tumors of the choroid. These tumors typically occur unilaterally in the juxtapapillary region in young, healthy, white females. The fundus appearance is a yellow-white or orange-red elevated lesion with sharply demarcated irregular borders. Potential complications include growth and visual compromise secondary to choroidal neovascularization. Management involves photodocumentation with annual funduscopic examination and daily Amsler Grid self assessment. Laser photocoagulation is advocated in the presence of choroidal neovascularization within the arcades. A 70-year-old male presented with a unilateral subretinal elevated yellow-orange mass. Although atypical in presentation, the lesion was diagnosed as a choroidal osteoma based on the funduscopic appearance, computed tomography, ultrasonography and serologic testing.

Isolated Ocular Cryptococcosis in an Immunocompetent Patient

A 62-year-old woman without evidence of immunocompromise was evaluated for uveitis and a subretinal lesion in the right eye. Laboratory evaluation, including cerebrospinal fluid analysis, revealed no apparent cause. The diagnosis of subretinal cryptococcosis was established by transscleral needle biopsy of the subretinal mass. Treatment with intravenous amphotericin B and oral 5-flucytosine brought recovery of visual acuity to 20/30-1 and resolution of the inflammation. This patient demonstrates that ocular cryptococcal infection must be suspected, even in the absence of predisposing factors or systemic findings, and that subretinal fine-needle aspiration is an important diagnostic tool in this setting.

Breast Carcinoma Metastatic to the Uvea

A 45-year-old woman with a 1-year history of adenocarcinoma of the breast, metastatic to axillary lymph glands and both lungs, presented with a chief complaint of decreasing visual acuity. Examination revealed a best-corrected visual acuity of 20/50 in each eye. Isolated yellow subretinal masses, several disc diameters in size, with overlying pigment dispersion and serous retinal detachments were present in both eyes. Each macula was similarly affected (Fig 1). A 57-year-old woman with a similar history presented with an amelanotic-appearing fluffy white mass in the temporal iris and an anterior chamber angle of her left eye, with seeding into the anterior chamber (Fig 2). Both women had developed metastases to the vascular layer of the eye, the uvea. The uvea consists of the choroid posteriorly and the iris and ciliary body anteriorly. Metastases from adenocarcinoma can occur in either location, but more commonly involve the choroid. 1 Metastatic carcinoma to

Subretinal fluid in the diagnosis of posterior scleritis

The etiology of subretinal mass lesions is very difficult to establish. A 28-year-old man presented to us with an area of choroiditis, which progressed, despite corticosteroid and antibiotic therapy, to an exudative retinal detachment, secondary glaucoma and a painful blind eye. To develop a means of identifying the cause of such lesions, we did a subretinal fluid tap prior to enucleation. Cytopathology showed only inflammatory cells and the final histopathological diagnosis was that of a granulomatous scleritis.

CHOROIDAL MALIGNANT MELANOMA WITH EARLY VITREOUS SEEDING

Primary choroidal malignant melanoma with extension through the overlying retina is a rarely reported entity, and to our knowledge actual seeding of the vitreous has never been reported. The pathologic findings in a 41-year-old woman who presented with a large amelanotic subretinal mass near the optic disc of the right eye are discussed. Fundus examination preoperatively revealed a concentration of discrete, fleshy, oval to round, vitreous bodies of varying size, limited to the area overlying the mass. Histopathology of this tumor revealed a spindle cell posterior choroidal melanoma with marked atrophy of the overlying retina. At the apex, the retina was discontinuous and melanoma cells extended into the overlying vitreous. Some of the cells surrounded asteroid bodies overlying the tumor, altering their clinical appearance. This behavior, while only involving a small fraction of the tumor cells, may imply a more aggressive tumor.

Clinical Manifestations of Brawny Scleritis

We studied four patients with posterior brawny scleritis. Two underwent enucleation for suspected melanoma, and in the other two, the correct diagnosis was made and effective therapy begun. Of seven other eyes with brawny scleritis from other sources, five were enucleated after diagnosis of choroidal melanoma and one for suspected intraocular tumor. This experience and other previous reports indicate the high incidence of diagnostic confusion regarding brawny scleritis. We therefore emphasized clinical symptoms and signs of brawny scleritis: inflammation, tenderness or pain of the globe, history of collagen vascular disease, proptosis, bilaterality, and retinal and choroidal detachment. A preserved normal choroidal vascular pattern over an elevated subretinal mass may be indicative of posterior brawny scleritis. Scleral biopsy is useful for tissue diagnosis. Radioactive phosphorus uptake tests and ultrasonography may erroneously indicate choroidal melanoma and lead to enucleation of a potentially salvageable globe.