RETINAL Cases & Brief Reports:
Goldman, Darin R. MD*,†; Barnes, Alexander C. BS‡; Vora, Robin A. MD*; Duker, Jay S. MD*
*New England Eye Center at Tufts Medical Center, Boston, Massachusetts;
†Ophthalmic Consultants of Boston, Boston, Massachusetts; and
‡Tuft University School of Medicine, Boston, Massachusetts.
Reprint requests: Jay S Duker, MD, New England Eye Center at Tufts Medical Center, 800 Washington Street, Box 450, Boston, MA 02111; e-mail: firstname.lastname@example.org
Supported in part by both Research to Prevent Blindness and Massachusetts Lions Eye Research Fund unrestricted award to the New England Eye Center/Department of Ophthalmology, Tufts University School of Medicine.
None of the authors have any conflicting interests to disclose.
To present a case of leaky choroidal nevus that responded favorably to treatment with focal laser photocoagulation, shown by spectral domain optical coherence tomography, fundus autofluorescence, and fundus photography.
Descriptive case report of a 40-year-old male patient with decreased visual acuity because of subretinal fluid associated with a choroidal nevus, which was treated with focal laser photocoagulation.
Treatment with focal laser photocoagulation to the surface of the choroidal nevus resulted in the resolution of subretinal fluid by 6 weeks. The therapeutic effect remained after 1 year of follow-up with continued improvement in vision and with no growth of the lesion.
Laser photocoagulation can be an effective treatment for symptomatic subretinal fluid associated with a choroidal nevus. Spectral domain optical coherence tomography, fundus autofluorescence, and fundus photography can be helpful in monitoring the treatment response.
Subretinal fluid (SRF) is an uncommon finding in the setting of a choroidal nevus, a feature that has become easier to identify with the use of optical coherence tomography (OCT).1 Various treatment modalities can be used to address symptomatic SRF in the setting of a choroidal nevus including photodynamic therapy,2 laser photocoagulation,3 and intravitreal bevacizumab.4
An otherwise healthy 40-year-old man was referred for further evaluation of a suspicious choroidal lesion. The patient reported a gradual decrease in visual acuity for the last 3 months associated with an intermittent shadow over his left eye. Best-corrected visual acuity was 20/30 in the affected left eye at presentation. Dilated fundus examination revealed a darkly pigmented choroidal lesion above the superior arcade. The lesion had distinct borders with overlying drusen and retinal pigment epithelial metaplasia (Figure 1, top left). There was no visible orange pigment on the surface of the lesion. At the inferior border of the lesion, there was a column of SRF gravitating into the fovea, which was confirmed through OCT (Figure 1, bottom left). The clinical features of this lesion, particularly the gravitational fluid tract, were best illustrated by fundus autofluorescence (Figure 1, right). B-scan ultrasonography measured the lesion to be 8 mm × 7 mm, with a height of 1.75 mm.
The lesion was initially observed without treatment. Three months after presentation, visual acuity decreased to 20/70 in the left eye. Though there was no increase in the dimensions of the lesion, there was an increase in submacular fluid involving the fovea, which was not associated with any choroidal neovascular membrane, as assessed by clinical examination and OCT. At this time, the lesion was believed to be a choroidal nevus and was treated with focal laser photocoagulation (Figure 2). Six weeks after the treatment, SRF resolved with improved visual acuity to 20/40. Repeat examination revealed light pigmentary surface changes from the laser treatment (Figure 3, top). Optical coherence tomography confirmed the resolution of SRF (Figure 3, bottom). Five months later, moderate outer retinal atrophy involving the superior macula remained and visual acuity was 20/40. One year later, SRF remained resolved and visual acuity was 20/30. The lesion remained unchanged in size and appearance.
Choroidal nevi are the most common intraocular tumor, found in ∼6% of adults.4,5 Because this benign tumor is derived from melanocytes, it has the potential to transform into a malignant melanoma, though this progression is rare (∼1 in 8,000).2,5 Predictive factors for malignant transformation include the presence of SRF, symptomatic presentation, tumor thickness >2 mm, orange pigment, and location within 3 mm of the optic disk.6 Subretinal fluid may not be as rare a finding in choroidal nevi as previously thought, with OCT's greater sensitivity identifying SRF in 26% of cases compared with a detection rate of 16% by clinical examination.1 The case presented highlights the SRF resolution in a choroidal nevus along with a concomitant gain in visual acuity after treatment with focal laser photocoagulation. It is worth noting that such patients require diligent follow-up with clinical examination and imaging (e.g., B-scan) because of the rare potential for malignant transformation. Previous reported cases have not illustrated with such clarity the connection between anatomical and functional improvement following laser therapy using spectral domain OCT, fundus autofluorescence, and color fundus photography.
Laser photocoagulation is indicated in the management of SRF secondary to choroidal nevi when evidence of foveal involvement exists. In this case, therapy was initiated after the development of visual loss subsequent to a period of close monitoring that indicated no tumor growth, allowing for a more definitive diagnosis of choroidal nevus.
In conclusion, we demonstrate the successful treatment of a leaky choroidal nevus by laser photocoagulation using multiple imaging modalities. One year after receiving the treatment, the patient's visual acuity remained improved with no recurrence of the SRF.
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