ARCH SOC ESP OFTALMOL. 2010;85(10):337–340 ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA
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Treatment with photodynamic therapy of circumscribed choroidal hemangioma J. Andonegui,* M. Pérez de Arcelus, L. Jiménez-Lasanta Servicio de Oftalmología, Hospital de Navarra, Pamplona, Spain
A RT I C L E I N F O R M AT I O N
A B S T R A C T
Case reports: The clinical characteristics of three patients with circumscribed choroidal
Received on June 3, 2010
haemangioma and subfoveal exudation detected by optical coherence tomography are described
Accepted on Oct. 5, 2010
in this paper. The three patients were successfully treated with photodynamic therapy. Discussion: Photodynamic therapy is the most adequate therapeutic option for circumscribed
choroidal hemangioma associated with subfoveal exudation. Some questions such as
whether attempts should be made to obtain a complete tumour regression, laser settings
or the way the spots must be applied remain unresolved. © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L.
All rights reserved.
Tratamiento mediante terapia fotodinámica del hemangioma coroideo circunscrito R E S U M E N
Casos clínicos: Se presentan las características clínicas de tres pacientes con hemangioma
Hemangioma coroideo circunscrito
coroideo circunscrito y exudación subfoveal, detectada mediante tomografía óptica de
coherencia, tratados con éxito mediante terapia fotodinámica.
Discusión: La terapia fotodinámica es actualmente la alternativa terapéutica más efectiva para tratar los hemangiomas coroideos circunscritos asociados a exudación subfoveal. Respecto a la utilización de este tratamiento quedan por definir algunas cuestiones como son si se debe buscar o no la desaparición total de la masa tumoral, los parámetros de láser más adecuados en estos casos o la forma de aplicación de los impactos. © 2010 Sociedad Española de Oftalmología. Publicado por Elsevier España, S.L. Todos los derechos reservados.
Introduction Circumscribed choroidal haemangioma is a benign hamartous vascular tumor. Clinically, it appears like a rounded or oval mass with poorly defined edges and orange or reddish color
located in the retroequatorial region. Many of these lesions can remain asymptomatic, but are frequently accompanied by subfoveal chronic exudation which diminishes visual acuity.1 This paper describes the clinical characteristics and evolution of three patients with circumscribed choroidal
*Corresponding author. E-mail: [email protected]
(J. Andonegui). 0365-6691/$ - see front matter © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights reserved.
ARCH SOC ESP OFTALMOL. 2010;85(10):337–340
Figure 1 – A) ocular fundus image showing an orange tumor in the superior temporal arch. B) OCT over the macular area shows subfoveal subretinal liquid accumulation. In addition, the mass effect of the tumor can be seen. C) Mode B ecography before PDT: solid, homogeneous and hyperintense mass without posterior acoustic shadow. D) Retinography after PDT. Persistence of the orange mass. E) OCT after treatment shows the absence of subretinal fluid and persistence of the mass effect of the tumor. F) Mode B ecography after PDT. The mass has not diminished significantly.
Figure 2 – A) ocular fundus image of the eye prior to therapy, showing an orange tumor in the suprapapillary area. B) OCT over the macular area exhibits subfoveal subretinal liquid. C) Mode B ecography before PDT. Solid, hyperintense and homogeneous mass without posterior acoustic shadow. D) appearance of the retina after PDT. E) Absence of subretinal fluid in OCT after the treatment. F) Ecography after PDT, showing a considerable reduction of the mass.
ARCH SOC ESP OFTALMOL. 2010;85(10):337–340
Figure 3 – A) ocular fundus image before the treatment, showing an orange tumor in the suprapapillary location. B) OCT over the macular area shows an accumulation of subfoveal subretinal liquid and an epiretinal membrane. C) Ecography before PDT: Solid, hyperintense and homogeneous mass without posterior acoustic shadow. D) appearance of the retina after 2 PDT sessions and after extracting the epiretinal membrane. E) OCT showing the absence of subretinal liquid and epiretinal membrane. F) remission of the tumor in Mode B ecography.
haemangioma and submacular serous detachment detected with optical coherence tomography (OCT) and successfully treated with photodynamic therapy (PDT).
Clinical cases Three patients with circumscribed choroidal haemangioma and serous subfoveal detachment were studied. The diagnostic was made on the basis of funduscopic findings, fluorescein angiography and ocular echography. In addition, optical coherence tomography was performed before and after treatment for all cases to determine the presence of subfoveal fluid (figs. 1-3). The three cases were treated with photodynamic therapy (PDT) with verteporfin, applying doses of 6 mg/m2 of bodily surface, an intensity of 600 mW/cm2 and an irradiating exposure of 50 J/cm2 during 83 seconds. A single spot was applied, covering the entire tumor and leaving a margin of 200 µ from the edge of the papilla. In two cases, the subfoveal liquid disappeared and visual acuity improved with a single application. In the third case, the treatment was repeated due to the absence of initial response, increasing irradiation exposure to 100 J/cm2 and the application time to 166 seconds. After this second application a positive response was obtained. This patient additionally exhibited a macular epiretinal membrane that was intervened with vitrectomy after the two PDT sessions. The data of these patients are included in table 1.
Discussion The treatment of circumscribed choroidal haemangioma is indicated for diminished visual acuity due to submacular serous detachment.1,2 This condition was treated utilizing argon laser photocoagulation, cobalt brachytherapy, rutenium or iodine, radiotherapy or transpupilar thermal therapy. In general, these treatments exhibit high iatrogeny and are associated to a high rate of relapses. In recent years, PDT has been described as a successful alternative for treating these patients.1-4 The therapy exhibits selected action on the vascular endothelium and respects the remaining structures. In addition, its iatrogeny is lower than that of other treatments.2 Despite the good results of this technique, some issues are not yet entirely clarified. Firstly, there is a debate about whether the objective of the treatment should be the complete disappearance of the tumor or only the reabsorption of the submacular fluid. Although in two of the three patients of this article the tumor disappeared almost entirely, the objective was the reabsorption of the submacular detachment. In a further case, a substantial visual acuity increase was obtained despite the persistence of the tumor mass. The total elimination of the hemangioma could require increasing the number of treatments or the power or duration of the laser, and this could cause vascular closure of the choriocapillaries and pigmentary alterations.2-4 In addition, it has not been demonstrated that total disappearance is associated to a lower percentage of subfoveal exudation relapses as against a partial persistence of the tumor.
ARCH SOC ESP OFTALMOL. 2010;85(10):337–340
Table 1 – Clinical patient data PATIENT
Age Sex VA pretreatment VA postreatment Height pretreatment Height postreatment Number of sessions Radiating exposure Time Reabsorption lSR Follow-up
71 M 0.2 0.5 4 mm 4 mm 1 50 J/cm2 83 seconds Yes 15 months
46 V Finger count 0.1 2.5 mm 1 mm 1 50 J/cm2 83 seconds Yes 9 months
73 M Finger counting 0.3 2.5 mm 1 mm 2 1st session 50 J/cm2; 2nd session 100 J/cm2 1st session 83 seconds; 2nd session 166 seconds Yes 10 months
The laser application parameters have not been agreed either. The IV verteporfin dose is usually of 6mg/m2 of body surface and the intensity of 600 mW/cm2. But while some authors obtained good results, utilizing in all cases the same values as in age-related macular degeneration (AMD), that is 50 J/cm2 of radiation exposure during 83 seconds,1,2,4 others propose applications of 100 J/cm2 during 166 seconds.3 The starting parameters of our study were those applied in AMD but in case 3, due to the poor initial response it was decided to double the values in the second treatment, obtaining a positive therapeutic effect. It seems likely that the laser application parameters should be adapted to the size of the tumor. The form of applying the laser is also controversial. In general, a single application covering the entire tumor is enough.3 This option, which was applied to the patients of this series, is less costly and complicated for patients. However, irradiation by means of multiple applications has also been proposed,2,5 either confluent or not, or limiting treatment to the most prominent part of the tumor. To conclude, PDT treatment of circumscribed choroidal hemangioma with subfoveal retina detachment appears as the most adequate therapeutic alternative at this time. We consider that the objective of the treatment should be the reabsorption of the subfoveal liquid. The application of a
single spot with the same parameters utilized in AMD could suffice to obtain this objective, although in some cases having more prominent tumors it might be necessary to increase said parameters.
R E F E R E N C E S
1. Madreperla SA. Choroidal hemangioma treated with photodynamic therapy using verteporfin. Arch Ophthalmol. 2001;119:1606-10. 2. Singh AD, Kaiser PK, Sears JE, Gupta M, Rundle PA, Rennie IG. Photodynamic therapy of circumscribed choroidal haemangioma. Br J Ophthalmol. 2004;88:1414-8. 3. Michels S, Michels R, Simader C, Schmidt-Erfurth U. Verteporfin therapy for choroidal hemangioma: a long-term follow-up. Retina. 2005;25:697-703. 4. Boixadera A, Arumí JG, Martínez-Castillo V, Encinas JL, Elizalde J, Blanco-Mateos G, et al. Prospective clinical trial evaluating the efficacy of photodynamic therapy for symptomatic circumscribed choroidal hemangioma. Ophthalmology. 2009;116:100-5. 5. López-Quero MC, Casas-Fernández A, Lucas-Elío G, RodríguezGonzález-Herrero ME, Marín-Sánchez JM. Circumscribed choroidal hemangioma treated with photodynamic therapy. Arch Soc Esp Oftalmol. 2008;83:553-7.