Group Title: Cases Journal 2009, 2:8778
Title: Spectral domain optical coherence tomography guided photodynamic therapy for choroidal hemangioma: a case report
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Title: Spectral domain optical coherence tomography guided photodynamic therapy for choroidal hemangioma: a case report
Series Title: Cases Journal 2009, 2:8778
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Creator: Chalam KV
Murthy RK
Gupta SK
Brar VS
Publication Date: 40066
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Volume ID: VID00001
Source Institution: University of Florida
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CASES

JOURNAL I


Case report


Spectral domain optical coherence tomography guided
photodynamic therapy for choroidal hemangioma: a case report
Kakarla V Chalam*, Ravi K Murthy, Shailesh K Gupta and Vikram S Brar

Address: Department of Ophthalmology, University of Florida, College of Medicine, West 8th Street, Tower II, Jacksonville, 32204, Florida, USA
Email: KVC* kchalam@jax.ufl.edu; RKM ravi.keshavamurthy@jax.ufl.edu; SKG shailesh.gupta@jax.ufl.edu; VSB vikram.brar@jax.ufl.edu
* Corresponding author

Received: 26 July 2009 Accepted: 13 August 2009 Published: 10 September 2009
Cases journal 2009, 2:8778 doi: 10.4076/1757-1626-2-8778
This article is available from: http://casesjournal.com/casesjournal/article/view/8778
2009 Chalam et al.; licensee Cases Network Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
Introduction: Circumscribed choroidal hemangiomas are vascular tumors associated with
secondary changes in the overlying retinal pigment epithelium and neuro-sensory retina. Spectral-
domain optical coherence tomography, a recent advancement in funds imaging techniques provides
high resolution images of the retina. We describe spectral domain Optical coherence tomography
findings in a case of circumscribed choroidal hemangioma which was successfully treated with
photodynamic therapy.
Case presentation: A 41-year-old white male presented with decreased vision in his right eye.
Fundus evaluation showed findings consistent with circumscribed choroidal hemangioma. Spectral-
domain optical coherence tomography revealed a large serious retinal detachment overlying the
tumor with an intact photoreceptor layer. The patient underwent photodynamic therapy and a
repeat tomography scan confirmed the resolution of serious detachment with return of normal foveal
contour.
Conclusion: Spectral domain optical coherence tomography is an emerging modality in imaging of
the retina and reveals ultrastructural changes occurring in various retina pathologies. In this case
report we illustrate the use of spectral domain optical coherence tomography for the first time to
document retinal changes overlying a choroidal hemangioma and its role as a non-invasive tool in
planning the treatment and prognosticating the final visual outcome following treatment for
circumscribed subfoveal choroidal hemangiomas.






Introduction treatment modalities have been described to treat chor-
Choroidal hemangiomas are vascular hamartomas of oidal hemangiomas including transcleral cryotherapy,
the choroid and can cause visual loss due to subfoveal radiotherapy, photocoagulation, and in recent times,
location, associated exudative retinal detachment, cystoid transpupillary thermotherapy and photodynamic therapy
macular edema or subretinal fibrosis [1,2]. A number of [3,6-8].


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Spectral domain OCT, in recent times, has been an
important advancement in OCT technology, having
enhanced speed and sensitivity in acquiring retinal images.
It acquires upto 40000 scans in a short period of time
and renders a 3-dimensional image with cross-sectional
sections providing detailed ultrastructural changes within
the retina [4]. In this case report, we document SD OCT
changes before and after photodynamic therapy in a case
of choroidal hemangioma.

Case presentation
A 41-year-old white male was referred to our clinic with a
diagnosis of right eye submacular edema of one week
duration. Systemically there was no associated diabetes
mellitus or hypertension. On examination his best
corrected visual acuity (BCVA) was 20/50 in the right eye
and 20/20 in the left eye. Near vision (J7) and color vision
were affected as well in the right eye. Anterior segment
examination was unremarkable and dilated funds
evaluation revealed a hypopigmented grey mass that
measured 4 disc diameters, located just temporal to the
fovea with overlying serious retinal detachment (Figure 1).
Fundus fluorescein angiography (Figure 2a) revealed well
defined areas of focal hyperfluorescence in the transit
phase with late pooling of the dye corresponding to the
overlying serious detachment. B scan ultrasonography
(Figure 2b) showed a subretinal mass which measured
5.3 mm at the base and 2.64 mm in thickness with
corresponding A-scan showing medium to high internal
reflectivity. Spectral domain OCT (Spectralis, Heidelberg
Engineering Inc) (Figure 3a) revealed a dome shaped
elevation of the choroid and focal hyperplasia of the
overlying RPE. There was an associated serious retinal
detachment overlying the tumor, measuring 957 pm in


Figure I. Color funds photograph of the right eye of the
patient.


height at the fovea, but the retinal architecture was
preserved with normal photoreceptor layer and absence
ofintraretinal edema. Systemic evaluation was negative for
occult malignancy and patient was diagnosed to have
solitary circumscribed choroidal hemangioma (CCH).
Photodynamic therapy was applied using a Zeiss laser
(Visulas II) emitting a light at 692 nm for photosensiti-
zation with prior systemic administration ofverteporphin
(Visudyne) at a dose of 6 mg/m2, with the spot size kept at
6000 microns. The patient was followed up after a week
and follow up BCVA was noted to be 20/30. A repeat
SD OCT was done which showed minimal residual
subretinal fluid, (foveal thickness measuring 269 pm)
and return of normal foveal architecture (Figure 3b).

Discussion
Choroidal hemangiomas are vascular hamartomas which
are classified based upon the extent of involvement into
two types: Diffuse hemangioma involving much of the
choroid in association with Sturge-Weber syndrome and
circumscribed involving a portion of the choroid with
no associated systemic features [1]. Histo-pathological
examinations of the eyes with choroidal hemangiomas
enucleated with a mistaken diagnosis of choroidal
melanoma have shown that solitary hemangiomas are
either cavernous hemangiomas or a mixture of cavernous
and capillary hemangiomas. Hyperplasia and fibrous
metaplasia of the overlying retinal pigment epithelium
are often noted [5].

Clinically on funds evaluation CCH is typically a solitary
dome shaped mass with an orange-red appearance. There
can be a grayish appearance due to the fibrous metaplasia
of the overlying retinal pigment epithelium [1]. The
diagnosis is based upon a strong index of suspicion and
presence of findings on A and B scan ultrasonography,
which typically show a solid mass with medium to high
reflectivity and acoustic solidity. Fibrous and osseous


Figure 2. (a) Fundus fluorescein angiography of the right eye.
(b) B-scan Ultra sonogram of the posterior segment.


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"3b
F-A


Figure 3. (a) SD OCT findings of the patient before treatment with photodynamic therapy. (b) SD OCT findings of the patient
after treatment with photodynamic therapy.


metaplasia of the overlying RPE when present can lead to
higher reflectivity [3].

SD OCT is a recent advancement in retinal imaging
systems, which uses a non-invasive confocal scanning laser
system that transforms a series of optical sections into a
layered three-dimensional image of the retina. It provides
a detailed image of the changes in the overlying RPE and
the neuro-sensory retina and help indirectly in prognos-
ticating the visual potential, following definitive treat-
ment. In our patient, SD OCT showed the preservation of
retinal architecture and absence of an intraretinal edema
overlying the tumor which helped in good prognostication
following effective treatment.

Photodynamic therapy (PDT) has been in recent times
found to be an effective treatment for solitary hemangiomas
[6-8]. PDT allows selective occlusion of the vascular lesions
without damaging the adjacent retinal structures. In our
case, patient showed symptomatic improvement following
PDT which was objectively demonstrated by the reappear-
ance of the normal foveal architecture, resolution of
subretinal fluid and disappearance of RPE changes on the
SD OCT. Favorable prognostic factors following treatment
for subfoveal circumscribed hemangiomas have been


described to be good initial visual acuity and duration of
the associated neurosensory detachment [2]. SD OCT by
demonstrating the changes in the overlying photoreceptor
layer can be a useful non invasive tool in prognosticating
the final visual outcome following treatment. Documenta-
tion of absence of leakage on Indocyaniane Green (ICG)
angiography is taken as a direct evidence for regression of
the tumor [9]. In our patient, serial SD OCT scans
eliminated the need for ICG angiography.

In conclusion, SD OCT is an emerging tool in the imaging
of retina and provides high definition ultrastructural
changes associated with vitreo-retinal disorders. In this
case report we illustrate the use of SD OCT for the first
time to document retinal changes overlying a choroidal
hemangioma and its role as a non-invasive tool in
planning the treatment and prognosticating the final
visual outcome following treatment for circumscribed
subfoveal choroidal hemangiomas.

Abbreviations
CCH, circumscribed choroidal hemagioma; ICG, indo-
cyanine green; PDT, photodynamic therapy; RPE, retinal
pigment epithelium; SD OCT, spectral domain optical
coherence tomography.

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Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.

Competing interests
The authors declare that they have no competing interests.

Authors' contributions
KC and SG identified the case and directly participated in
management. They also revised the manuscript and
verified its intellectual content. VB and RM worked in
collaboration to collect data, acquire clinical photographs,
and draft, revise, and reference the manuscript.

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