1. ENHANCED DEPTH IMAGING OPTICAL
COHERENCE TOMOGRAPHY OF
CHOROIDAL METASTASIS IN 14 EYES
SAAD A. AL-DAHMASH, MD, CAROL L. SHIELDS, MD, SWATHI KALIKI, MD,
TIMOTHY JOHNSON, MD, JERRY A. SHIELDS, MD
Purpose: To describe the imaging features of choroidal metastasis using enhanced
depth imaging optical coherence tomography (EDI-OCT).
Methods: This retrospective observational case series included 31 eyes with choroidal
metastasis. Spectral domain EDI-OCT was performed using Heidelberg Spectralis HRA +
OCT. The main outcome measures were imaging features by EDI-OCT.
Results: Of 31 eyes with choroidal metastasis imaged with EDI-OCT, 14 (45%) eyes
displayed image detail suitable for study. The metastasis originated from carcinoma of the
breast (n = 7, 50%), lung (n = 5, 36%), pancreas (n = 1, 7%), and thyroid gland (n = 1, 7%).
The mean tumor basal diameter was 6.4 mm, and mean thickness was 2.3 mm by B-scan
ultrasonography. The tumor location was submacular in 6 (43%) eyes and extramacular in 8
(57%) eyes. By EDI-OCT, the mean tumor thickness was 987 mm. The most salient
EDI-OCT features of the metastasis included anterior compression/obliteration of the over-
lying choriocapillaris (n = 13, 93%), an irregular (lumpy bumpy) anterior contour (n = 9,
64%), and posterior shadowing (n = 12, 86%). Overlying retinal pigment epithelial abnor-
malities were noted (n = 11, 78%). Outer retinal features included structural loss of the
interdigitation of the cone outer segment tips (n = 9, 64%), the ellipsoid portion of photo-
receptors (n = 8, 57%), external limiting membrane (n = 4, 29%), outer nuclear layer (n = 1,
7%), and outer plexiform layer (n = 1, 7%). The inner retinal layers (inner nuclear layer to
nerve fiber layer) were normal. Subretinal fluid (n = 11, 79%), subretinal lipofuscin pigment
(n = 1, 7%), and intraretinal edema (n = 2, 14%) were identified.
Conclusion: The EDI-OCT of choroidal metastasis shows a characteristic lumpy bumpy
anterior tumor surface and outer retinal layer disruption with preservation of inner retinal layers.
RETINA 34:1588–1593, 2014
Conventional spectral domain (SD) optical coher-
ence tomography (OCT) provides cross-sectional
retinal images with an axial resolution of 5 mm.1
The limitations of conventional SD-OCT include poor
image resolution of structures deep to the retinal
pigment epithelium (RPE), particularly the choroid,
due to light scattering from the RPE and the vascular
interfaces of the choroid. Further limitations are related
to motion artifact with subtle eye movement and occa-
sional inaccurate determination of RPE/choriocapillaris
layer by the automated software, which necessitates
manual correction for OCT thickness measurements.1,2
Enhanced depth imaging (EDI)-OCT, a method
described by Spaide et al,2
was designed to improve
imaging of the deeper layers of the eye, primarily the
choroid and sclera. The technique of EDI-OCT has
been used to characterize the normal features and thick-
ness of the choroid in various age groups and refractive
states, as well as the features in selected diseases.3–9
Furthermore, EDI-OCT features of choroidal and
scleral tumors have been published, particularly regard-
ing choroidal nevus, melanoma, choroidal lymphoma,
From the Ocular Oncology Service, Wills Eye Institute, Thomas
Jefferson University, Philadelphia, Pennsylvania. Dr. Al-Dahmash is
now at the Ophthalmology Department, College of Medicine, King
Saud University, Riyadh, Saudi Arabia; and Dr. Kaliki is now at the
Ocular Oncology Service, L V Prasad Eye Institute, Hyderabad, India.
None of the authors have any conflicting interests to disclose.
Supported by the Eye Tumor Research Foundation, Philadelphia,
PA (C.L.S. and J.A.S.).
Carol L. Shields has had full access to all the data in the study
and takes responsibility for the integrity of the data and the accu-
racy of the data analysis.
Reprint requests: Carol L. Shields, MD, Ocular Oncology
Service, Suite 1440, Wills Eye Institute, Thomas Jefferson
University, 840 Walnut Street, Philadelphia, PA 19107; e-mail:
carol.shields@shieldsoncology.com
1588
2. sclerochoroidal calcification, and solitary idiopathic
choroiditis.10–15
Distinguishing features are many, but
the anterior surface of tumors can vary slightly with
a smooth mound shape of nevus, a dome shape of
a small melanoma, and a “seasick” surface of advanced
lymphoma.11–13
Simulating lesions also show charac-
teristic surfaces such as a “rocky and rolling” surface of
sclerochoroidal calcification and a scalloped contour of
choroidal hemorrhage.14,16
Herein, we describe the
“lumpy bumpy” anterior surface of choroidal metastasis
on EDI-OCT and delineate other related features.
Methods
This was a retrospective observational study
approved by the Institutional Review Board of Wills
Eye Hospital. All patients diagnosed with choroidal
metastasis from January 1, 2011 to November 31, 2011
at the Ocular Oncology Service, Wills Eye Hospital,
Philadelphia, PA, underwent EDI-OCT using SD
imaging with the Heidelberg Spectralis (Heidelberg
Engineering, Heidelberg, Germany). Patients with
choroidal metastasis measuring ,3.5 mm thickness
by ultrasonography were included for the study.
The patient demographic data of age, race, and
gender were recorded. The presenting symptoms,
primary malignancy site, and best-corrected visual
acuity were listed. The choroidal metastasis was
evaluated for clinical features including quadrantic
location of the tumor epicenter, maximal basal diam-
eter (in millimeters), distance of the posterior margin
of the metastasis from the foveola and the optic disk
(in millimeters), color (pigmented, nonpigmented, or
mixed), and overlying RPE alterations (none, atrophy,
or hypertrophy). The presence of subretinal fluid,
lipofuscin pigment, and drusen was also noted. These
findings were documented with a large fundus drawing
and confirmed by fundus photography and ultraso-
nography. The features recorded on standard ultraso-
nography included the thickness (in millimeters),
configuration (plateau, dome, or mushroom), echoge-
nicity (solid or hollow), choroidal excavation (absent
or present), and subretinal fluid (absent or present).
Spectral domain EDI-OCT was performed using
a Heidelberg Spectralis HRA + OCT (Heidelberg
Engineering) and acquisition and analysis software
(version 5.3.3.0) with automated EDI. The axial reso-
lution was 3.5 mm with a scan speed of 40,000 A-scans
per second. The images were captured using a custom
scan acquisition protocol of up to 13 raster lines of
9-mm scan length, with 1,536 A-scans per line. Real-
time eye tracking by TruTrack Active Eye Tracking
was used, and automatic real-time image averaging
was set at 100 images. Enhanced depth imaging optical
coherence tomography was performed using a technique
similar to that described by Spaide et al.2
The EDI-OCT images were obtained after pupillary
dilatation in all patients. They were evaluated for
quality (optimal or suboptimal). The EDI-OCT image
was considered optimal and suitable for the study
when both anterior and posterior margins of the tumor
and the overlying retina were visualized, as well as the
lateral margins of the tumor. The images were
classified as suboptimal when a portion of the tumor
or the overlying retina could not be visualized and
were excluded from the study. The optimal EDI-OCT
images were then reviewed. The recorded features
included thinning of the choriocapillaris (absent or
present), the contour of the anterior surface of the
tumor (smooth or lumpy bumpy), internal quality of
the tumor, maximal tumor thickness (in micrometers),
and posterior choroidal shadowing (absent or present).
The retinal layers were evaluated for abnormalities
(absent, atrophy, hypertrophy, irregularity, or thin-
ning) of the RPE, the interdigitation of the cone outer
segment tips, ellipsoid portion of photoreceptors,
external limiting membrane, outer nuclear layer, outer
plexiform layer, inner nuclear layer, inner plexiform
layer, ganglion cell layer, and nerve fiber layer. The
presence of subretinal fluid, drusen, and orange
pigment were noted and correlated with clinical and
fundus autofluorescence findings.
Results
Of 31 eyes with choroidal metastases that underwent
EDI-OCT imaging over an 11-month period, the quality
of the image was judged to be optimal in 14 eyes (45%)
and suboptimal in 17 eyes (55%). The quality of
suboptimal images was found with peripherally located
tumors (at or anterior to the equator), thick tumors
(.2 mm thickness), presence of media opacity, and in
elderly or sickly patients uncooperative for proper
imaging. This did not correlate to tumor type. The clin-
ical and ultrasonographic features of the choroidal
metastasis are summarized in Table 1. Of 14 eyes
(13 patients) with optimal EDI-OCT image, the mean
age was 63 years (median, 63 years; range, 43–80
years) (Figures 1 and 2). Ocular symptoms were present
in 13 (93%) eyes, and 1 (7%) patient was asymptom-
atic. The primary malignancy was carcinoma of the
breast (n = 7, 50%), lung (n = 5, 36%), pancreas (n =
1, 7%), and thyroid gland (n = 1, 7%).
The epicenter of the choroidal metastasis was
located within the macula (n = 6, 43%) or outside
the macula (n = 8, 57%). The mean maximal basal
EDI-OCT OF CHOROIDAL METASTASIS AL-DAHMASH ET AL 1589
3. diameter of the choroidal metastasis was 6 mm
(median, 5.0 mm; range, 3.0–12.0 mm). Subretinal
fluid was clinically visible in 79% (n = 11) of the
cases. Other clinical findings included RPE atrophy
(n = 3, 21%), RPE hyperplasia (n = 2, 14%), and
orange pigment (n = 1, 7%). Ultrasonography showed
mean thickness of choroidal metastasis at 2.3 mm
(median, 2.3 mm; range, 1.0–3.3 mm).
The EDI-OCT characteristics of choroidal metasta-
sis are summarized in Table 2. The average thickness
of the choroidal metastasis measured by EDI-OCT was
987 mm (median, 1,014 mm; range, 547–1,511 mm).
The EDI-OCT features included choriocapillaris com-
pression/obliteration (n = 13, 93%), homogeneous
optical reflectivity along the anterior surface, and the
anterior tumor surface being lumpy bumpy (n = 9,
64%) or smooth (n = 5, 36%). The internal quality
of the tumor could not be evaluated because of EDI-
OCT light signal attenuation (shadowing) (n = 12,
86%). The numerous RPE and retinal irregularities
are listed in Table 2. The inner retinal layers were
normal in all eyes.
Discussion
In 1997, Shields et al17
surveyed 520 eyes with cho-
roidal metastases and noted most tumors of small size
with mean thickness of 3 mm and with tumor epicenter in
the macular region or between the macula and the equa-
tor. The small size and posterior location of most choroi-
dal metastases render these tumors ideal for study with
OCT. Early reports on time domain and SD-OCT fea-
tures of choroidal tumors were mainly focused on over-
lying retinal features because choroidal imaging was
relatively poor.18–29
Schaudig et al18
recognized the lim-
itations of the OCT and suggested that OCT was of little
value in the differential diagnosis of choroidal tumors.
Arevalo et al20
described time-domain OCT findings
in 7 patients with choroidal metastasis and noted sub-
retinal fluid (86%), thickened RPE choriocapillaris
complex (71%), and little detail of the choroidal fea-
tures. Natesh et al21
reviewed time domain OCT find-
ings in 10 cases of choroidal metastases and noted
elevation of the RPE and retina, RPE thickening and
folds, and subretinal fluid. Sayanagi et al,22
in their
general report on SD-OCT of choroidal tumors,
described thickening and hyperreflectivity of the
RPE, overlying retinal thinning, and subretinal fluid
in 4 eyes with choroidal metastasis. They concluded
that visualization of the choroidal tumor was limited to
the anterior aspect with little deeper detail.22
Others
have noted similar findings, particularly with marked
“irregularity” in the RPE layer.23
Table 1. Enhanced Depth Imaging OCT of 14 Eyes
(13 Patients) With Choroidal Metastasis: Demographics
and Clinical Features
Features
Number (%)
(n = 14)
Age, mean (median, range), years 63 (63, 43–80)
Race
White 13 (100)
Others 0 (0)
Gender
Male 2 (15)
Female 11 (85)
Symptoms
None 1 (7)
Present 13 (93)
Primary malignancy
Breast 7 (50)
Lung 5 (36)
Pancreas 1 (7)
Thyroid 1 (7)
Visual acuity
$20/40 4 (29)
,20/40–20/100 7 (50)
,20/100 3 (22)
Location of choroidal metastasis
epicenter
Macula 6 (43)
Extramacular 8 (57)
Distance from the foveola, mean
(median, range), mm
2.0 (2.0, 0–4.0)
Distance from the optic disk, mean
(median, range), mm
2.0 (1.0, 0–7.0)
Maximal basal diameter, mean
(median, range), mm
6.0 (5.0, 3.0–12.0)
Ultrasonographic thickness, mean
(median, range), mm
2.3 (2.3, 1.0–3.3)
Color
Melanotic 1 (7)
Amelanotic 13 (93)
Mixed 0 (0)
Subretinal fluid
Present 11 (79)
Absent 3 (21)
RPE changes
None 9 (64)
Atrophy 3 (22)
Hyperplasia 2 (14)
Orange pigment
Absent 13 (93)
Present 1 (7)
Drusen
Absent 14 (100)
Present 0 (0)
Ultrasonographic configuration
Plateau 1 (7)
Dome 13 (93)
Mushroom 0 (0)
Ultrasonographic hollowness 4 (29)
Choroidal excavation 2 (14)
1590 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2014 VOLUME 34 NUMBER 8
4. In our study, using high-resolution SD EDI-OCT,
the most salient feature of choroidal metastasis was the
irregular or lumpy bumpy anterior tumor surface (64%
of cases) despite a smooth-appearing surface on
ultrasonography. Unlike the smooth “mound” of cho-
roidal nevus and the smooth “dome” of melanoma,
choroidal metastasis often showed characteristic
lumpy bumpy surface. Choroidal metastasis is an infil-
trative process, which is believed to start at the cho-
riocapillaris level. The resolution of EDI-OCT depicts
this malignancy with choriocapillaris compression/
obliteration, similar to nevus and melanoma.11,12
Overlying attenuation of the outer retinal layers and
RPE was evident in many cases (Table 2). Retinal
pigment epithelial abnormalities were clinically visible
in 36% compared with EDI-OCT-visible in 78%.
An additional benefit of EDI-OCT is the detection
of tiny subclinical choroidal metastasis before they are
ophthalmoscopically visible, as highlighted by Torres
et al10
and Witkin et al.30
In this series, we imaged
tumors as small as 547 mm. In these cases, the tumor
was present in the outer choroid with loss of large
choroidal vessels and nearly invisible to ophthalmos-
copy and ultrasonography.
Previous reports on choroidal nevus and small
choroidal melanoma have identified the incongruity
between ultrasonography and EDI-OCT measurement
of tumor thickness.11,12
Likewise, the same discrep-
ancy was noted for choroidal metastasis thickness by
ultrasonography versus EDI-OCT. On ultrasonogra-
phy, the mean tumor thickness was 2.3 mm compared
with 0.987 mm on EDI-OCT, an overestimation by
133% on ultrasonography. This could represent more
precise measurement with high-resolution EDI-OCT
or could be the result of calibration discrepancy with
either technique or could be related to misplacement of
the calipers on low-resolution ultrasonography. Witkin
et al30
noted that tumors ,1 mm in thickness could be
undetectable by ultrasonography and better visualized
with EDI-OCT. Although our study includes a few
patients, we believe that EDI-OCT has shown an obvi-
ous improvement over ultrasound for anatomical
depiction and resolution of tumor. This alone contrib-
utes to our recognition and understanding of this
malignancy and could be instrumental in following
tumor regression after treatment.
In conclusion, SD EDI-OCT is a promising non-
invasive tool for high-resolution imaging of choroidal
Fig. 1. Enhanced depth imag-
ing OCT of choroidal metastasis
in a 51-year-old woman. A. The
amelanotic choroidal metastasis
is visible superotemporal to the
optic disk. B. Enhanced depth
imaging OCT at the center of the
tumor showing slightly irregular
lumpy bumpy anterior tumor
surface, obliteration/compres-
sion of choriocapillaris, and
choroidal shadowing. There is
overlying RPE thinning, struc-
tural loss of the interdigitation of
the cone outer segment tips, and
the ellipsoid portion of photo-
receptors with intact inner retinal layers. C. Enhanced depth imaging OCT at the fovea demonstrates subretinal fluid.
Fig. 2. Enhanced depth imaging
OCT of choroidal metastasis in
a 63-year-old woman. A. The
amelanotic choroidal metastasis
is visible superotemporal to the
optic disk. B. Enhanced depth
imaging OCT at the center of the
tumor showing the typical lumpy
bumpy anterior tumor surface.
There is overlying RPE atrophy
and irregularity, structural loss of
the interdigitation of the cone
outer segment tips, and the
ellipsoid portion of photo-
receptors with intact inner retinal
layers. C. Enhanced depth
imaging OCT at the fovea demonstrates subretinal fluid.
EDI-OCT OF CHOROIDAL METASTASIS AL-DAHMASH ET AL 1591
5. metastasis, which allows visualization of tumor details
and overlying retina. The most obvious finding is the
lumpy bumpy tumor surface of choroidal metastasis,
as well as overlying subretinal fluid and choriocapil-
laris compression/obliteration. These findings can
assist the clinician in the early detection of choroidal
metastasis and in the differentiation of choroidal
metastasis from simulating conditions.
Key words: eye, tumor, choroid, metastasis, optical
coherence tomography, enhanced depth imaging, EDI-
OCT.
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Table 2. Enhanced Depth Imaging OCT of 14 Eyes With
Choroidal Metastasis: EDI Characteristics of Choroid and
Retinal Structures
Features Number (%) n = 14
Choriocapillaris
Normal 1 (7)
Thinning 13 (93)
Anterior tumor surface contour
Lumpy bumpy 9 (64)
Smooth 5 (36)
Thickness of metastasis, mean
(median, range), mm
987 (1,014, 547–1,511)
Choroidal shadowing
Absent 2 (14)
Present 12 (86)
Bruch membrane
Intact 14 (100)
Ruptured 0 (0)
RPE
Normal 3 (22)
Atrophy 1 (7)
Hypertrophy 5 (36)
Thinning 5 (36)
Interdigitation of the cone outer
segment tips
Normal 5 (36)
Absent 9 (64)
Ellipsoid portion of
photoreceptors
Normal 6 (43)
Absent 8 (57)
External limiting membrane
Normal 9 (64)
Irregular 1 (7)
Absent 4 (29)
Outer nuclear layer
Normal 13 (93)
Absent 1 (7)
Outer plexiform layer
Normal 13 (93)
Absent 1 (7)
Inner nuclear layer and inward
Normal 14 (100)
Abnormal 0 (0)
Associated features
Subretinal fluid 11 (79)
Subretinal lipofuscin
deposition (orange pigment)
1 (7)
Intraretinal cystoid edema 1 (7)
Intraretinal noncystoid edema 1 (7)
1592 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2014 VOLUME 34 NUMBER 8
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EDI-OCT OF CHOROIDAL METASTASIS AL-DAHMASH ET AL 1593
