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| CASE REPORT |
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| Year : 2023 | Volume
: 16
| Issue : 1 | Page : 151-153 |
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De novo choroidal osteoma after laser photocoagulation of a peripapillary choroidal neovascular membrane
Omar Salehi1, C Alex Harper2, Robyn Guymer3, Roderick O'Day2
1 Department of Surgery, University of Melbourne, Melbourne, Australia
2 Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
3 Department of Surgery, University of Melbourne; Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| Date of Submission | 29-Mar-2022 |
| Date of Decision | 27-Jun-2022 |
| Date of Acceptance | 14-Nov-2022 |
| Date of Web Publication | 21-Feb-2023 |
Correspondence Address:
Omar Salehi
University of Melbourne, Melbourne
Australia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.ojo_83_22
 Abstract | | |
We describe the case of a 76-year-old man who developed an asymptomatic choroidal osteoma in the left eye 10 years after receiving retinal laser photocoagulation for treatment of a peripapillary choroidal neovascular membrane. The choroidal osteoma presented as a progressively enlarging, well-circumscribed yellow lesion adjacent to the region of retinal fibrosis. Optical coherence tomography showed a choroidal lesion with superficial lamellations and ultrasonography demonstrated increased echogenicity. The choroidal osteoma was not encroaching on the fovea and is currently being monitored. This is only the third report of a de novo choroidal osteoma developing subsequent to retinal laser photocoagulation.
Keywords: Choroidal, osteoma, tumor
How to cite this article:
Salehi O, Harper C A, Guymer R, O'Day R. De novo choroidal osteoma after laser photocoagulation of a peripapillary choroidal neovascular membrane. Oman J Ophthalmol 2023;16:151-3 |
How to cite this URL:
Salehi O, Harper C A, Guymer R, O'Day R. De novo choroidal osteoma after laser photocoagulation of a peripapillary choroidal neovascular membrane. Oman J Ophthalmol [serial online] 2023 [cited 2023 Mar 31];16:151-3. Available from: https://www.ojoonline.org/text.asp?2023/16/1/151/370064 |
| Introduction | |  |
Choroidal osteoma is a rare, benign, and ossifying choristoma consisting of mature bone deposition in the choroid of unknown pathogenesis.
The lesion presents as a well-defined, peripapillary, and yellow-white slightly elevated mass that may be accompanied by depigmentation of the overlying retinal pigment epithelium. Outer retinal degeneration or choroidal neovascularization can lead to vision loss.[1] The largest case series to date reported only 61 patients over 26 years at the Wills Eye Hospital Ocular Oncology Service.[2]
Choroidal osteomas are predominantly idiopathic; however, there have been two previous cases of these tumors arising in areas treated with retinal laser photocoagulation.[3],[4] Our report describes the de novo occurrence of choroidal osteoma after laser photocoagulation treatment for choroidal neovascular membrane (CNVM).
| Case Report | | |
A 76-year-old, otherwise healthy, Caucasian male was referred for evaluation of a progressively enlarging choroidal lesion superotemporal to the left optic nerve head in February 2021. The patient was visually asymptomatic. He had a previous history of a peripapillary CNVM in that eye that was successfully treated with argon laser photocoagulation 10 years prior. Other history included stable intermediate age-related macular degeneration and a small, left-sided choroidal nevus with no risk factors for malignant transformation.
Best-corrected visual acuity was 6/6 in both eyes. Fundus examination showed a well-demarcated, yellow lesion superotemporal to the optic nerve head. The lesion was adjacent to an area of retinal atrophy due to prior laser photocoagulation for peripapillary CNVM [Figure 1]a and [Figure 1]b. Review of previous retinal images showed that the mass first developed in 2014 and has progressively enlarged since that time. The lesion was located in the choroid on optical coherence tomography (OCT) [Figure 1]c and [Figure 1]d. The mass was approximately 900 μm thick and demonstrated superficial lamellations on enhanced depth imaging-OCT. B-scan ultrasonography showed high reflectivity at the level of the choroid [Figure 2]. | Figure 1: (a) Color fundus photography of the left eye in 2011 demonstrating a region of peripapillary atrophy postlaser photocoagulation for the treatment of choroidal neovascular membrane (black arrow). (b) Color fundus photography of the left eye in 2017 demonstrating a well-demarcated, yellow lesion suggestive of choroidal osteoma (white arrow) developing adjacent to the previous area of peripapillary fibrosis. The left eye OCT demonstrating outer retinal atrophy postlaser photocoagulation (c and d) a choroidal mass consistent with choroidal osteoma (yellow star). OCT: Optical coherence tomography
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 | Figure 2: B-scan ultrasonography of the left eye in 2021 showing a 0.15 cm hyperechoic choroidal lesion (red arrow) with posterior acoustic shadowing (yellow arrow)
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There was no overlying subretinal fluid or lipofuscin accumulation. A clinical diagnosis of a choroidal osteoma adjacent to the previous retinal photocoagulation scar was made. As the patient was asymptomatic and the mass was not encroaching on the fovea, the lesion is currently being observed.
| Discussion | | |
Choroidal osteoma was first described by Gass et al., in 1978 as a well-demarcated, yellow-orange lesion with surface branching vessels initially believed to affect young and healthy women.[5] The etiology and pathogenesis of this condition are poorly understood but may involve congenital, inflammatory, hormonal, and hereditary factors.[1] Most tumors are slow growing with an average annual growth of 0.37 mm in basal diameter.[2] Choroidal osteoma may be asymptomatic in the early stages; however, progressive visual impairment can occur secondary to outer retinal loss, often occurring after spontaneous decalcification of a subfoveal tumor or CNVM formation.[6]
Multimodal imaging can be used to assist with diagnosis and assessment of severity. A-scan ultrasound demonstrates a high-intensity echo spike, whereas B-scan ultrasound shows a slightly elevated choroidal mass with high reflectivity and posterior acoustic shadowing.
OCT is useful to better characterize tumor size, depth of invasion, regions of decalcification, and presence of subretinal fluid or CNVM. Varying levels of decalcification, 'retinal pigment epithelium (RPE) atrophy, and accumulation of lipofuscin yield different patterns on fundus autofluorescence imaging. Regions of tumor decalcification tend to cause reduced autofluorescence while calcified regions may have preserved or increased autofluorescence.[1],[7]
Spontaneous tumor decalcification can occur in up to 50% of cases. Subfoveal lesions are associated with poor visual outcomes, as decalcification causes RPE and choriocapillaris atrophy which may lead to photoreceptor loss.[2] Management options for extrafoveal tumors to prevent subfoveal spread include the use of laser photocoagulation or photodynamic therapy.[8] In cases complicated by CNVM, the use of anti-vascular endothelial growth factor injections, photodynamic therapy, or transpupillary thermal therapy has also been reported.[1]
To the best of our knowledge, our report describes only the third case of de novo formation of a choroidal osteoma arising subsequent to retinal laser photocoagulation.
Gass cites a case of an elderly man with macular degeneration who received laser treatment for a CNVM that subsequently developed a choroidal osteoma adjacent to the laser photocoagulation scar.[4] No further clinical information is provided and the publication cited is not present on PubMed or online at the Archives of Ophthalmology.
Adhi et al. described the case of a 62-year-old male who developed a left-sided choroidal osteoma approximately 8 years following laser photocoagulation for the treatment of branch retinal vein occlusion. On a routine follow-up visit, he was found to have a well-circumscribed yellow-orange lesion in the macular region on fundus photography. B-scan ultrasonography demonstrated a choroidal mass in the posterior pole with increased reflectivity and posterior acoustic shadowing consistent with a choroidal osteoma. Eighteen months later, the tumor was complicated by CNVM causing acute vision impairment in the left eye. The patient was successfully treated with intravitreal bevacizumab.[3]
The pathogenesis of choroidal osteoma is not well understood but may involve hereditary, inflammatory, and endocrinological factors.[1] Enucleated specimens show that choroidal osteomas are choristomas consisting of mature bone and not dystrophic calcification, which occurs in diseased tissue.[9]
It has been proposed that choroidal ossification may occur due to perturbation in the local environment related to chronic inflammation. The inflammatory response may cause the release of various cytokines and growth factors known to promote differentiation of pericytes, a type of pluripotent mesenchymal stem cell within the choriocapillaris, into osteoprogenitor cells capable of generating mineralized bone.[10] In our case, as well as the previously reported cases, laser photocoagulation may have induced an inflammatory response which subsequently triggered localized derangement and inflammation leading to choroidal osteoma formation. However, this is purely speculative, and the de novo development of this tumor may also be entirely coincidental.
In conclusion, we describe the case of asymptomatic choroidal osteoma that developed adjacent to a laser photocoagulation scar in an eye previously treated for CNVM.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Alameddine RM, Mansour AM, Kahtani E. Review of choroidal osteomas. Middle East Afr J Ophthalmol 2014;21:244-50.  [ PUBMED] [Full text] |
| 2. | 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. |
| 3. | Adhi M, Bryant JS, Alwassia AA, Chen C, Duker JS. De novo appearance of a choroidal osteoma in an eye with previous branch retinal vein occlusion. Ophthalmic Surg Lasers Imaging Retina 2013;44:77-80. |
| 4. | Gass JD. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 4 th ed. Mosby: Anne S. Patterson; 1997. |
| 5. | Gass JD, Guerry RK, Jack RL, Harris G. Choroidal osteoma. Arch Ophthalmol 1978;96:428-35. |
| 6. | Aylward GW, Chang TS, Pautler SE, Gass JD. A long-term follow-up of choroidal osteoma. Arch Ophthalmol 1998;116:1337-41. |
| 7. | Olguin-Manríquez F, Enríquez AB, Crim N, Meraz-Gutierrez M, Soberón-Ventura V, Ávila I, et al. Multimodal imaging in choroidal osteoma. Int J Retina Vitreous 2018;4:30. |
| 8. | Mazloumi M, Dalvin LA, Ancona-Lezama D, Mashayekhi A, Shields CL. Photodynamic therapy for extrafoveolar choroidal osteoma. Retina 2020;40:966-71. |
| 9. | Ramzi S, Cotran VK, Collins T. Robbins' Pathologic Basis of Disease. 6 th ed. Elsevier Health Sciences: WB Saunders; 1999. |
| 10. | Munteanu M, Munteanu G, Giuri S, Zolog I, Motoc AG. Ossification of the choroid: Three clinical cases and literature review of the pathogenesis of intraocular ossification. Rom J Morphol Embryol 2013;54:871-7. |
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