Transpupillary thermotherapy in the management of circumscribed choroidal hemangioma

Abstract

Laser photocoagulation and various radiation therapy methods have been used in the treatment of circumscribed choroidal hemangioma that produce visual loss. Recently, transpupillary thermotherapy has been employed in the management of choroidal hemangioma. Thirty-six cases of choroidal hemangioma treated with transpupillary thermotherapy are reviewed. Twenty-eight cases were reported in the literature and 10 cases were managed by the author. Transpupillary thermotherapy has been used as a primary treatment (36 cases) or secondary treatment (2 cases) for choroidal hemangioma. The goal of transpupillary thermotherapy is to achieve resolution of exudative detachment of the fovea and improvement of vision. In all eyes the foveal detachment subsided. In 26 eyes having pretreatment visual acuity ≥0.05 (20/400), the visual acuity increased in 20 (77%) eyes and remained unchanged in 6 (23%) eyes. After transpupillary thermotherapy, 16 (42%) cases showed complete regression, 20 (53%) demonstrated partial regression, and in 2 (5%) there was no change in tumor thickness at follow-ups ranging from 2 to 44 months. Complications of transpupillary thermotherapy of choroidal hemangioma included cystoid macular edema (3 eyes), preretinal fibrosis (2 eyes), focal iris atrophy (3 eyes), and retinal vascular occlusion (1 eye). Although the follow-up in many studies is limited, transpupillary thermotherapy has not been associated with any significant complications.

Introduction

Choroidal hemangioma is a benign vascular tumor. It is generally believed that the tumor is present at birth or develops by early adulthood. In time, it produces visual symptoms leading to clinical recognition. Choroidal hemangioma can be classified in two forms: a diffuse type and a circumscribed type based on the extent of choroidal involvement.38., 41. The diffuse choroidal hemangioma is associated with Sturge-Weber syndrome. The circumscribed choroidal hemangioma (CCH) is usually a sporadic tumor not associated with any systemic manifestations, although it can rarely be associated with Sturge-Weber syndrome or its variations, probably representing a limited form of the syndrome.

On funduscopy, CCH presents as an orange-red mass. A- and B-mode ultrasonography show that the CCH has a dome shape, medium to high reflectivity, and acoustic solidity.35., 38. Fibrous or osseous metaplasia on the tumor surface, if present, may produce higher reflectivity and may lead to orbital shadowing.³⁸ Fluorescein angiography shows early fluorescence in the prearterial and arterial phase followed by moderate hyperfluorescence in the venous phase and increasing hyperfluorescence in the late phase.³⁵ There may be leakage into the subretinal space in the late frames. Indocyanine green angiography demonstrates extreme hyperfluorescence in the early frame by about 1 minute followed by moderate hyperfluorescence in the middle and late frames (at approximately 8 and 20 minutes respectively).³⁵ This early hyperfluorescence followed by relative hypofluorescence has been referred to as the washout phenomenon and is characteristic for CCH.³² This washout phenomenon has not been observed with other intraocular tumors.³²

CCH can cause visual loss through a variety of associated conditions, including exudative retinal detachment, cystoid macular edema, subretinal fibrosis, subfoveal tumor location, and, rarely, neovascular glaucoma.1., 41. Asymptomatic CCH not causing visual loss does not require treatment and can be observed periodically. CCH that produces visual loss due to subretinal fluid has been treated by transscleral cryopexy, diathermy, photocoagulation, or radiotherapy. Photocoagulation and radiotherapy have become more popular than other modalities because of their efficacy and ease of applicability. However, these two methods have certain disadvantages in the treatment of CCH. As a result, there has been interest in alternative treatment methods, including photodynamic therapy (PDT)2., 11., 17., 27., 29., 31. and transpupillary thermotherapy (TTT).7., 8., 12., 20., 22., 24.

Treatment options for diffuse choroidal hemangioma producing exudative retinal detachment include laser photocoagulation and external beam radiotherapy. If the exudative retinal detachment is extensive, vitrectomy, gas injection, and endophotocoagulation may become necessary.16., 28., 38. Diffuse choroidal hemangioma is not a good candidate for PDT or TTT, which are used for localized lesions.

The purpose of this article is to review the current status of TTT in the management of CCH. Search of the Internet library of medicine through the PubMed database revealed six reports published on the subject to date in the English literature.7., 8., 12., 20., 22., 24. Data from the 28 cases reported in these papers are combined with data from 10 cases managed by the author to provide an overview of 38 cases of CCH treated with TTT.