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Management of choroidal hemangioma By Hany EL-Defrawy, MVR Fellow BEH

Diffuse choroidal hemangioma Rare Sporodic Neuro-Oculocutaneous disorder Facial nevus flammeus Buphthalmos Diffuse choroidal hemangioma (Tomato-Catsup) Leptomeningeal hemangiomatosis Epilepsy MR Hemiplegia

Circumscribed choroidal hemangioma Uncommon, benign vascular tumour Discrete, smooth round orange red mass Macular and peripapillary region

Causes of visual loss1. Refractive error2. Foveal distortion3. Transudative leakage and CMO4. Serous Retinal detachment with secondary photoreceptor damage

Diagnosis Ultrasongraphy FFA OCT MRI

When to treat? Visual acuity potential Extent of detachment

Why challenging? Limitedtherapeutic options (Why?) Surgery (Dangerous)

 Size Location Associated SRF

Armamentarium External beam radiation therapy (5 observational studies) Proton beam therapy Brachytherapy Photodynamic therapy Cryotherapy Transpupillary thermotherapy Anti VEGF IVTA Combined therapy

Radiation Cataract Radiation optic neuropathy Retinopathy Increase incidence of osteosarcoma Chorioretinal atrophy

Other modalities Plaque Brachytherapy1. Murthy 20052. Zografos 1996 Proton Beam Stereotactic therapy (Gamma Knife) Anti VEGF PDT

PDT Anand 2003 Bains et al 2004 Singh et al 2005 Huiskamp 2005 Tsipursky

Ophthalmology 2009;116:100-105

 31 patients with CCH and symptoms Underwent PDT IV Verteporfin 6 mg/m 2 689nm laser 15 min laser 50j/cm 2 83 sec exposure 1-4 treatment Follow up 12 month

 Primary end point1. Absence of exudative RD at 12 month follow up (FFA,OCT, Ophthalmoscopy) Secondary endpoint1. Visual acuity2. Tumour thickness decrease3. Adverse events

 Inclusion criteria1. 18 with CCH height 5 mm and diameter 12 mm2. Exudative RD affecting the fovea3. No cataract within last 2 months Exclusion criteria1. NYHA Class III-IV2. Porphyria3. Liver disease4. Active hepatitis

Results 82.8% 1 session 13.8% 2 sessions 3.4% 3 sessions Visual acuity increased mean 20/60 to 20/ 35 CMO regressed and Exudative RD disappeared in all except 2 cases. CCH thickness decreased from 3 to 1.7 mm Visual fields showed resolution of central scotomas No adverse events

Am J ophthalmol 2010

 Retrospective study of 14 patients with symptommatic circumscribed choroidal hemangioma who underwent PDT± IVTA  Shao Huang, James Fabian etal. Optometery and visual science , 2009.

 Symptomatic visual loss Exudative Detachment Macular edema Subfoveal fluid Tumour encroaching to within 2 mm of the fovea.

 7.5 mm spot size Overlapping spots 83 sec IVTA (0.1ml of 40 mg/ml) Baseline VA IOP Macular thickness 10 eyes PDT 4 PDT and IVTA

Conclusion Optimal treatment settings remains a matter of debate for CCH Variable number of spots Ranging Spot size (2500-7700µ) Ranging duration (60-83sec) Overlapping vs non overlapping spots Number of treatment sessions

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by Hany El-Defrawy on Aug 15, 2012

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