Download Grand Rounds - University of Louisville Ophthalmology

Retina Imaging Conference
Brett Mueller, D.O., Ph.D.
2/11/2016
University of Louisville
Department of Ophthalmology and Visual Sciences
Patient Presentation

CC: Decreased Vision Left Eye

HPI: 59 yo WM presents w/ gradual, painless blurry
vision OS that has been getting worse for the past
several months. Pt denies any history of trauma, HAs, or
jaw claudication.
History
POHx: none
PMHx: Hypertension and controlled on medical management
FAMHx: none
ROS: none
MEDS: Metoprolol, aspirin, and a statin
ALLERGIES: none
Exam
18
20/20 (+1.25 sph)
VA
TP
20/CF 1 ft (+1.75 sph)
3→2
P
20
3→2
NO RAPD
EOM: full OU
Exam
OD
OS
LIDS/LASHES
WNL
WNL
CONJ
WNL
WNL
CORNEA
WNL
WNL
IRIS
WNL
WNL
LENS
1+NS
1+NS
Fundus Photos
OD
OS
IR Photos
OD
OS
FAF Photos
OD
OS
OCT
OD
Macula
OS
Macula
OCT
OS
Below the Fovea
OS
Through the Nevus
FA
Early Venous Phase
00:12:00
Late Phase
02:00:00
FA/ICG
Summary
59 y/o WM with decreased vision OS. Examination and FA reveal a
choroidal neovascular membrane w/ a concomitant choroidal nevus
DDx:
 Choroidal neovascular membrane
 Idiopathic ?
 Nevus ?
PLAN: Avastin injection with 1 month f/u
Exam s/p 2 Avastin
Injections
16
20/20 (+1.25 sph)
VA
TP
20/300 (+1.75 sph)
3→2
P
16
3→2
no RAPD
EOM: full OU
OCT
OS
OCT
OS
Below the Fovea
OS
Through the Nevus
Cause of the CNVM
Is it due to the choroidal nevus?
Or is it an idiopathic CNVM?
Complications of Choroidal Nevi
Numerous studies postulate that the prevalence of
choroidal nevi in the general population is anywhere
from 0.2% - 30%
 Most use 6.5% as the incidence of nevi in the general
population
Sumich P, Mitchell P, Wang JJ. Choroidal nevi in a white population: the Blue Mountains Eye Study. Arch
Ophthalmol. 1998 May;116(5):645-50. PubMed PMID: 9596501
Naumann GOHHellner KNaumann LR Pigmented nevi of the choroid: clinical study of secondary
changes in the overlying tissues. Trans Am Acad Ophthalmol Otolaryngol.1971;75110- 123
Complications of Choroidal Nevi
Decreased visual acuity attributable to
Serous foveal detachment
Photoreceptor degeneration
CNVM
Blue Mountains Eye Study: None had complications
associated with vision loss
Gonder JR, Augsburger JJ, McCarthy EF, Shields JA. Visual loss associated with choroidal nevi.
Ophthalmology. 1982 Aug;89(8):961-5. PubMed PMID: 6182515.
Sumich P, Mitchell P, Wang JJ. Choroidal nevi in a white population: the Blue Mountains Eye Study. Arch
Ophthalmol. 1998 May;116(5):645-50. PubMed PMID: 9596501
Complications of Choroidal Nevi
22 of 206 patients (11%) with choroidal lesions had
decreased VA attributable to :
 Serous foveal detachment (50%)
 Photoreceptor degeneration (42%)
 CNVM (8%)
322 eyes with giant choroidal nevi, 2.2% had
decreased vision
Gonder JR, Augsburger JJ, McCarthy EF, Shields JA. Visual loss associated with choroidal nevi. Ophthalmology. 1982
Aug;89(8):961-5. PubMed PMID: 6182515.
Li HK, Shields CL, Mashayekhi A, Randolph JD, Bailey T, Burnbaum J, Shields JA. Giant choroidal nevus clinical features
and natural course in 322 cases. Ophthalmology. 2010 Feb;117(2):324-33. doi: 10.1016/j.ophtha.2009.07.006. Epub 2009
Dec 6. PubMed PMID: 19969359.
Complications of Choroidal Nevi
Choroidal Nevus Risk Factors for Vision loss
 Nevus proximity to foveola (0 mm vs > 0 mm): RR = 36.46
 Subretinal fluid (> 3 to 6 mm vs none): RR = 498.33
 RPE detachment (present vs absent):RR = 33.01
 CNVM (present vs absent): RR = 98.72
Li HK, Shields CL, Mashayekhi A, Randolph JD, Bailey T, Burnbaum J, Shields JA. Giant choroidal nevus clinical features
and natural course in 322 cases. Ophthalmology. 2010 Feb;117(2):324-33. doi: 10.1016/j.ophtha.2009.07.006. Epub 2009
Dec 6. PubMed PMID: 19969359.
Shields CL, Furuta M, Mashayekhi A, Berman EL, Zahler JD, Hoberman DM, Dinh DH, Shields JA. Visual acuity in 3422
consecutive eyes with choroidal nevus. Arch Ophthalmol. 2007 Nov;125(11):1501-7. PubMed PMID: 17998511.
Why the Difference Between the
Studies
In the Blue Mountains Eye Study, the average
diameter for the nevus was between 1-2mm, with
1.5% of them being over 4mm
Wills Eye 3,000+ patients with choroidal nevi have
an average diameter of 5.1-5.7mm
Conclusion
Is the CNVM secondary to the choroidal nevus?
Or is it just an idiopathic CNVM, and the choroidal
nevus is just an innocent bystander
Choroidal nevi can cause decreased VA
 Proximity to the fovea
 Subretinal fluid
 RPE detachment
 CNVM
THANK YOU
References
1.
2.
3.
4.
Retina and Vitreous, BCSC
Ophthalmic Pathology and Intraocular Tumors, BCSC
American Academy of Ophthalmology eye wiki website on idiopathic CNVMs
Krypton laser photocoaguluation for idiopathic neovascular lesions: results of a randomized clinical trial. Photocoagulation Study
Group. Arch Ophthalmol. 1990; 108: 832-837
5.
Persistent and recurrent NV after krypton laser photocoagulation for NV lesion of ocular histoplasmosis. Macular Photocoagulation
Study Group. Arch Ophthalmol. 1989; 107:344-352
6.
Kanski’s Clinical Ophthalmology A systemic Approach, Eighth Edition. Brad Bowling
7. Gonder JR, Augsburger JJ, McCarthy EF, Shields JA. Visual loss associated with choroidal nevi. Ophthalmology. 1982
Aug;89(8):961-5. PubMed PMID: 6182515.
8.
D.G. Callanan, M.L. Lewis, S.F. Byrne, J.D.M. Gass Choroidal neovascularization associated with choroidal nevi Arch Ophthalmol,
111 (1993), pp. 789–794
9.
Gass JD Problems in the differential diagnosis of choroidal nevi and malignant melanoma: XXXIII Edward Jackson Memorial
lecture. Trans Am Acad Ophthalmol Otolaryngol.1977;8319- 48
10. Ganley JPComstock GW Benign nevi and malignant melanomas of the choroid. Am J Ophthalmol. 1973;7619- 25
11. Naumann G Pigmented nevi of the choroid and ciliary bodies: a clinical and histopathological study. Adv Ophthalmol. 1970;23187- 272
12. Hale PNAllen RAStraatsma BR Benign melanomas (nevi) of the choroid and ciliary body. Arch Ophthalmol. 1965;74532- 538
13. Wilder HC Intraocular tumors in soldiers: World War II. Mil Surg. 1946;99459- 490
14. Lang GKDaumann FJ Peripheral fundus changes in subjects with healthy eyes (pilots). Klin Monatsbl Augenheilkd. 1982;181493- 495
Link to Article
15. Albers EC Benign melanomas of the choroid and their malignant transformation. Am J Ophthalmol. 1940;23779- 783
16. Albert DMRobinson NLFulton AB et al. Epidemiological investigation of increased incidence of choroidal melanoma in a single
population of chemical workers. Int Ophthalmol Clin.1980;2071- 92
17. Albert DMSearl SSForget BLavin PTKirkwood JNordlund JJ Uveal findings in patients with cutaneous melanoma. Am J
Ophthalmol. 1983;95474- 479
18. Rodriguez Sains RS Ocular findings in patients with dysplastic nevus syndrome. Ophthalmology. 1986;93661- 665
19. Smith REGanley JP Ophthalmic survey of a community, I: abnormalities of the ocular fundus. Am J Ophthalmol. 1972;741126- 1130
20. Sumich P, Mitchell P, Wang JJ. Choroidal nevi in a white population: the Blue Mountains Eye Study. Arch Ophthalmol.
1998 May;116(5):645-50. PubMed PMID: 9596501
Idiopathic CNVM
Is a disease of exclusion that can be made after all
other causes associated with CNV have been ruled
out:
 Angioid streaks
 High myopia
 AMD
 Chorioretinal inflammatory conditions
 Tumors
 Trauma
Idiopathic CNVM
Some speculate that it could represent POHS
w/o the punched-out chorioretinal lesion
Other speculate that it could be a variant of
AMD w/out drusen or RPE abnormalities
Krypton laser photocoaguluation for idiopathic neovascular lesions: results of a randomized clinical trial.
Photocoagulation Study Group. Arch Ophthalmol. 1990; 108: 832-837
Persistent and recurrent NV after krypton laser photocoagulation for NV lesion of ocular histoplasmosis. Macular
Photocoagulation Study Group. Arch Ophthalmol. 1989; 107:344-352