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Vitrectomy for circumscribed choroidal hemangioma with exudative retinal detachment refractory to transpupillary thermotherapy

Shukla, Dhananjay MS; Ramasamy, Kim DNB

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Indian Journal of Ophthalmology: Jul–Aug 2007 - Volume 55 - Issue 4 - p 298-299
doi: 10.4103/0301-4738.33044
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Abstract

Choroidal hemangioma is a benign vascular tumor that can occur as a circumscribed mass without systemic associations or a diffuse lesion associated with the Sturge-Weber syndrome.1 Circumscribed choroidal hemangioma (CCH) may cause moderate visual impairment by exudative macular detachment, due to its location in/around the posterior pole.12 Currently, photodynamic therapy (PDT) and transpupillary thermotherapy (TTT) are the preferred treatment options.1 We describe a patient who developed a total retinal detachment after TTT for CCH and was successfully treated with vitrectomy and endophotocoagulation. We are not aware of any previous report of significant functional improvement with vitrectomy in a similar condition.

Case History

A 33-year-old man presented with blurred vision in the left eye for three weeks. On examination, best-corrected visual acuity (BCVA) was 20/20 right eye and 20/200 left eye. Left eye fundus revealed a paramacular orange-red subretinal lesion with exudative detachment involving the macula and the lower half of the retina. Ultrasonography showed a localized choroidal thickening with moderate-high internal reflectivity. Fluorescein angiography revealed nonspecific hyperfluorescence, increasing in the late phases. The patient was explained the options of PDT and TTT; he opted for the latter due to financial constraints. TTT was done on a slit-lamp-mounted delivery system (IRIS Medical, Iridex Corp, Mountain View, CA). Threshold power was determined with a nasal test-spot. Using five overlapping 2 mm spots, marginally-suprathreshold burns were delivered (540 mW, 1min), to obtain a faint retinal blanching. A week postTTT, the patient presented with vitreous haze and increased retinal detachment; BCVA had reduced further to 13/200 Fig. 1A. The initial management was conservative, with topical/posterior-subtenon corticosteroids. When the detachment persisted for a month, the patient was explained the need for PDT / vitrectomy/referral for radiotherapy elsewhere. The patient preferred vitrectomy, which was performed with endophotocoagulation over the tumor (Frequency-doubled Nd:YAG laser, 250 to 300 mW, 0.1 to 0.15 second, 203 spots) and silicon oil tamponade. Oil was removed after four months. No recurrence/re-detachment was observed till the last visit (10 months); BCVA improved to 20/80 Fig. 1B.

Figure 1A
Figure 1A:
Preoperative fundus photograph showing the circumscribed choroidal hemangioma along the superotemporal arcade, with total retinal detachment and vitreous haze following unsuccessful thermotherapy. Snellen visual acuity was 13/200. Figure 1B: Six months after vitrectomy, endophotocoagulation and silicon oil removal, the tumor and detachment are completely resolved. The visual acuity has improved to 20/80. Photocoagulation marks nasal to the disc surround the endo-drainage site

Discussion

The decision to treat a CCH should be individualized according to the extent of symptoms, tumor location and visual potential.1 Though PDT is emerging as the treatment of choice, there is still a place for photocoagulation, TTT and irradiation, depending on the aforementioned parameters.12 TTT, however, may cause visually significant complications.3 It is therefore not recommended for subfoveal/juxtafoveal/peripapillary tumors.123 We experienced worsening of the exudative detachment after TTT for an extrafoveal CCH. The tumor however regressed completely after vitrectomy: endo-drainage of the subretinal fluid facilitated direct photocoagulation of the tumor and silicon oil tamponade probably prevented re-accumulation of the exudative fluid in the immediate postoperative period. The surgery could also have helped by removing the inflammatory mediators. Though others have attempted vitrectomy in extensive detachment with CCH, the aim was to avoid neovascular glaucoma/enucleation, rather than functional improvement.2 A Japanese study reported recurrence of exudative detachment after vitrectomy for a CCH (subsequently treated with TTT).4 Our case presents a reverse course of events in context of treatment sequence and results. We removed silicon oil later than they did (four weeks); and did not observe any recurrence for six months subsequently. We propose vitrectomy with endophotocoagulation as a viable alternative in the management of CCH with extensive retinal detachment.

1. Singh AD, Kaiser PK, Sears JE. Choroidal hemangioma Ophthalmol Clin North Am. 2005;18:151–61
2. Shields JA, Shields CL, Materin MA, Marr BP, Demirci H, Mashayekhi A. Changing concepts in management of circumscribed choroidal hemangioma: The 2003 J. Howard Stokes Lecture, Part 1 Ophthalmic Surg Lasers Imaging. 2004;35:383–94
3. Gunduz K. Transpupillary thermotherapy in the management of circumscribed choroidal hemangioma Surv Ophthalmol. 2004;49:316–27
4. Hirakata A, Okada AA, Asakawa M, Mitsui K, Hida T. A case of choroidal hemangioma with bullous exudative retinal detachment treated successfully by transpupillary thermotherapy Nippon Ganka Gakkai Zasshi. 2001;105:415–20
Keywords:

Circumscribed choroidal hemangioma; transpupillary thermotherapy; vitrectomy.

© 2007 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow