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 Table of Contents    
CLINICAL QUIZ
Year : 2016  |  Volume : 9  |  Issue : 3  |  Page : 193  

An 18-year-old female with unilateral painless vision loss


Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication14-Oct-2016

Correspondence Address:
Koushik Tripathy
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-620X.192311

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How to cite this article:
Wadekar B, Tripathy K, Chawla R, Venkatesh P, Sharma YR, Vohra R. An 18-year-old female with unilateral painless vision loss . Oman J Ophthalmol 2016;9:193

How to cite this URL:
Wadekar B, Tripathy K, Chawla R, Venkatesh P, Sharma YR, Vohra R. An 18-year-old female with unilateral painless vision loss . Oman J Ophthalmol [serial online] 2016 [cited 2019 Jul 18];9:193. Available from: http://www.ojoonline.org/text.asp?2016/9/3/193/192311

An 18-year-old female presented with painless diminution of vision in the right eye for 2 months. She had best corrected visual acuity of 1/60 in the right eye and 6/6 in the left eye. Anterior segment examination and intraocular pressure were normal in both eyes. There were no cells in the anterior chamber or retrolental space. Fundus of the left eye was within normal limits. Fundus photograph and optical coherence tomography (OCT) of the right eye are given in [Figure 1] and [Figure 2]. Ultrasonogram (USG) of the right eye is given in [Figure 3].
Figure 1: Fundus photograph of right eye

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Figure 2: Optical coherence tomograph of the right eye

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Figure 3: Ultrasonogram of the right eye

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   Questions Top


1. Describe the findings in [Figure 1],[Figure 2] na d[Figure 3]. What is the diagnosis?

2. What other investigations will you like to do to confirm the diagnosis?

Answers for Clinical Quiz


   Answers Top


1. [Figure 1] shows a well-demarcated, slightly elevated reddish orange lesion near optic disc, measuring  3*3 disc diameters, with a round grayish-black membrane at its center. Associated subretinal bleed, subretinal fluid (SRF) and hard exudates are seen. OCT [Figure 2] shows SRF along with a hyper-reflective subretinal membrane nasal to the SRF suggestive of choroidal neovascular membrane (CNVM). USG of the right eye showed a highly reflective homogenous thickened choroidal lesion which persisted at low gain and showed acoustic shadowing [Figure 3]. The features are suggestive of choroidal osteoma with active CNVM in the right eye.

2. Other investigations included fundus fluorescein angiogram (FFA) and computed tomography (CT) scan of orbit. FFA showed early, irregular, diffuse mottled hyperfluorescence, and late staining suggestive of osteoma. The membrane over osteoma showed early hyperfluorescence increasing in size and intensity in the later phases suggestive of active CNVM [Figure 4]. CT scan showed a hyperdense (bone density) mass lesion at ocular coats near optic disc within the right eye.
Figure 4: Fundus fluorescein angiogram of the right eye

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   Discussion Top


Choroidal osteoma is a rare benign ossifying tumor first described by Gass et al. [1] Typically, it affects one eye of young healthy females, manifesting as a well-defined, slightly elevated, yellow-white or orange lesion in the peripapillary, or macular choroid. Poor vision occurs due to SRF with or without underlying CNVM, [2] or photoreceptor atrophy at fovea. [3] CNVM occurs in 31% eyes in 10 years. [4] Laser, photodynamic therapy (PDT), transpupillary thermotherapy, and surgical removal have been tried with mixed results in CNVM associated with osteoma. However, recently there has been a surge of literature on the efficacy of anti-vascular endothelial growth factors (VEGF) for the condition. [3] Our patient received three intravitreal bevacizumab (1.25 mg in 0.05 ml) injections in the right eye at one monthly intervals. The SRF, subretinal bleed and hard exudates resolved with the improvement of vision to 6/12 in the right eye at 7 months follow-up, without recurrences [Figure 5]. Khan et al. [3] suggest monthly intravitreal anti-VEGF therapy for extrafoveal tumors, until resolution followed by consolidation PDT. For subfoveal disease, monthly intravitreal anti-VEGF until control, followed by treat-and-extend approach has been suggested. PDT should better be avoided in subfoveal cases due to the risk of vision loss from photoreceptor loss due to decalcification of the tumor. However, optimal therapy is yet to be established for the condition. Intravitreal anti-VEGF agents promise to be critical in the management of such cases at present and in the future.
Figure 5: Fundus photograph of the right eye after three intravitreal bevacizumab injection

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Acknowledgments

The authors are grateful to Trina Sengupta Tripathy for her immense support during preparation of manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


   References Top


  1. Gass JD, Guerry RK, Jack RL, Harris G. Choroidal osteoma. Arch Ophthalmol 1978;96:428-35.
  2. Song JH, Bae JH, Rho MI, Lee SC. Intravitreal bevacizumab in the management of subretinal fluid associated with choroidal osteoma. Retina 2010;30:945-51.
  3. Khan MA, DeCroos FC, Storey PP, Shields JA, Garg SJ, Shields CL. Outcomes of anti-vascular endothelial growth factor therapy in the management of choroidal neovascularization associated with choroidal osteoma. Retina 2014;34:1750-6.
  4. Shields CL, Sun H, Demirci H, Shields JA. Factors predictive of tumor growth, tumor decalcification, choroidal neovascularization, and visual outcome in 74 eyes with choroidal osteoma. Arch Ophthalmol 2005;123:1658-66.





    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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