Download Larson, C

Diagnosis and management of idiopathic sclerochoroidal calcification
Christian Larson, OD
Minneapolis VAMC Optometry Resident
Abstract:
Sclerochoroidal calcification is a rare, benign disorder that presents in elderly patients
and is commonly misdiagnosed as a choroidal malignancy. Sclerochoroidal calcification
may be indicative of an underlying systemic condition that produces dystrophic
electrolyte levels.
I. Case History
a. Patient demographics: 81 year old white male
b. Chief complaint: Physician directed diabetic eye exam
c. Ocular history: Pseudophakia OU, no history of diabetic retinopathy
d. Medical history: Type II diabetes mellitus, hypertension, hyperlipidemia,
sleep apnea, osteoarthritis, chronic back pain, anxiety, hearing loss, and
chondrocalcinosis
e. Current medications: Olanzapine, citalopram, mirtazapine,
hydrochlorothiazide diltiazem, losartan, simvastatin, diclofenac,
gentamicin ointment, psyllium, colchicine
II. Pertinent Findings
a. Two amelanotic elevated lesions, one disc diameter in size are observed in
superior temporal arcades, not noted at last dilated exam 4 years prior
b. Spectral OCT confirms mildly elevated sub-choroidal mass with intact
overlying retina
c. B-Scan shows hyper-reflection with posterior echoing
d. Previous blood plasma testing showed elevated blood glucose and a
decreased glomerular filtration rate. Plasma calcium levels were normal.
III. Differential Diagnoses
a. Sclerochoroidal calcification
i. Idiopathic, typically benign elevated white mass
ii. Presents in older, white males, bilaterally, in superior temporal
arcades most commonly
iii. B-scan shows hyperreflectivity with posterior echoing
b. Choroidal osteoma
i. Commonly presents in younger patients, located around optic
nerve, and is often large in size
ii. May result in choroidal neovascularization
iii. B-scan shows hyperreflectivity with posterior echoing
c. Choroidal lymphoma
i. May present as amelanotic lesion
ii. B-scan shows medium internal reflectivity
iii. Systemic lymphoma must be treated, may be life threatening
d. Choroidal melanoma
i. May present as amelanotic lesion
ii. B-scan shows medium internal reflectivity
iii. Metastasis is common, vision prognosis is poor, may be life
threatening
IV. Diagnosis and Discussion
a. Sclerochoroidal calcification
i. Fits demographics of patient
ii. Typically bilateral presentation
iii. Condition is normally benign and idiopathic
iv. Choroidal neovascularization and serous retinal detachments have
been reported
v. Condition is frequently misdiagnosed, has been treated as though it
were a melanoma
vi. Visual prognosis is typically very good, as macula is not
commonly affected
vii. Underlying systemic diseases can lead to dystrophic calcium levels
viii. Echoing on ultrasonography is important in helping distinguish this
calcified tumor from softer sub-choroidal lymphomas and
melanomas
V. Treatment/Management
a. Regular dilated eye exams to monitor for retinal detachment, CNVM
recommended
b. Blood work should be updated to rule out any underlying systemic
pathologies
i. Evaluate for kidney function/electrolyte levels
ii. Potential treatment of associated systemic conditions
c. Proper documentation and patient education to prevent unnecessary
intervention
d. No treatment of condition is usually warranted
e. Bibliography
i. Damato BE, Heimann H, Kalirai H, Coupland SE. Age, Survival
Predictors, and Metastatic Death in Patients With Choroidal
Melanoma: Tentative Evidence of a Therapeutic Effect on
Survival. JAMA Ophthalmol. 2014;132(5):605-613.
ii. Honavar SG, Shields CL, Demirci H, Shields JA. Sclerochoroidal
Calcification: Clinical Manifestations and Systemic Associations.
Arch Ophthalmol. 2001;119(6):833-840.
iii. Lee B, Pulido JS, Buettner H, Salomão D, Zent CS, Link TP.
Intravascular B-Cell Lymphoma (Angiotropic Lymphoma) With
Choroidal Involvement. Arch Ophthalmol. 2006;124(9):13571359.
iv. Leys A, Stalmans P, Blanckaert J. Sclerochoroidal Calcification
With Choroidal Neovascularization. Arch Ophthalmol.
2000;118(6):854-857.
v. Schachat AP, Robertson DM, Mieler WF, et al. Sclerochoroidal
Calcification. Arch Ophthalmol. 1992;110(2):196-199.
vi. Shields CL, Furuta M, Thangappan A, et al. Metastasis of Uveal
Melanoma Millimeter-by-Millimeter in 8033 Consecutive Eyes.
Arch Ophthalmol. 2009;127(8):989-998.
vii. Shields CL, Sun H, Demirci H, Shields JA. Factors Predictive of
Tumor Growth, Tumor Decalcification, Choroidal
Neovascularization, and Visual Outcome in 74 Eyes With
Choroidal Osteoma. Arch Ophthalmol. 2005;123(12):1658-1666.
viii. Shields JA. Sclerochoroidal Calcification in Calcium
Pyrophosphate Dihydrate Deposition Disease (Pseudogout). Arch
Ophthalmol. 1997;115(8):1077-1079.
ix. Wong CM, Kawasaki BS. Idiopathic Sclerochoroidal Calcification.
Optom Vis Sci. 2014; 91(2):32-37.
VI. Clinical Pearls/Conclusion
a. B-scan’s ability to show hyper-reflection with echoing can be
vital in diagnosis
b. Blood work should be ordered or available to rule out any other
underlying systemic conditions
c. Sclerochoroidal calcification should be considered a differential diagnosis
to prevent what may be unnecessary intervention. Spotting mildly
elevated, amelanotic lesions during a dilated exam can be an unsettling
experience. Consideration of additional risk factors and performance of
ultrasonography can allow providers to make an accurate diagnosis of a
relatively benign condition.