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PDT for choroidal hemangioma. Case presentation and review of literature

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  1. 1. Management of choroidal hemangioma By Hany EL-Defrawy, MVR Fellow BEH
  2. 2. Diffuse choroidal hemangioma Rare Sporodic Neuro-Oculocutaneous disorder Facial nevus flammeus Buphthalmos Diffuse choroidal hemangioma (Tomato-Catsup) Leptomeningeal hemangiomatosis Epilepsy MR Hemiplegia
  3. 3. Circumscribed choroidal hemangioma Uncommon, benign vascular tumour Discrete, smooth round orange red mass Macular and peripapillary region
  4. 4. Causes of visual loss1. Refractive error2. Foveal distortion3. Transudative leakage and CMO4. Serous Retinal detachment with secondary photoreceptor damage
  5. 5. Diagnosis Ultrasongraphy FFA OCT MRI
  6. 6. When to treat? Visual acuity potential Extent of detachment
  7. 7. Why challenging? Limitedtherapeutic options (Why?) Surgery (Dangerous)
  8. 8.  Size Location Associated SRF
  9. 9. Armamentarium External beam radiation therapy (5 observational studies) Proton beam therapy Brachytherapy Photodynamic therapy Cryotherapy Transpupillary thermotherapy Anti VEGF IVTA Combined therapy
  10. 10. Radiation Cataract Radiation optic neuropathy Retinopathy Increase incidence of osteosarcoma Chorioretinal atrophy
  11. 11. Other modalities Plaque Brachytherapy1. Murthy 20052. Zografos 1996 Proton Beam Stereotactic therapy (Gamma Knife) Anti VEGF PDT
  12. 12. PDT Anand 2003 Bains et al 2004 Singh et al 2005 Huiskamp 2005 Tsipursky
  13. 13. Ophthalmology 2009;116:100-105
  14. 14.  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
  15. 15.  Primary end point1. Absence of exudative RD at 12 month follow up (FFA,OCT, Ophthalmoscopy) Secondary endpoint1. Visual acuity2. Tumour thickness decrease3. Adverse events
  16. 16.  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
  17. 17. 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
  18. 18. Am J ophthalmol 2010
  19. 19.  Retrospective study of 14 patients with symptommatic circumscribed choroidal hemangioma who underwent PDT± IVTA  Shao Huang, James Fabian etal. Optometery and visual science , 2009.
  20. 20.  Symptomatic visual loss Exudative Detachment Macular edema Subfoveal fluid Tumour encroaching to within 2 mm of the fovea.
  21. 21.  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
  22. 22. 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