Retina Quiz
Retinal Lesion Throws Quarterback for a Loss
Mark T. Dunbar, O.D.A 26-year-old quarterback for the Miami Dolphins experienced blurryvision and metamorphopsia in his left eye during training camp. He thoughtit would go away, but when the symptoms persisted for several days he wentto his eye doctor.
Best-corrected visual acuities were 20/20 in the right eye and 20/70in the left. Confrontation visual fields were full to careful finger counting.The pupils were equally round and reactive with no afferent defect. Amslergrid testing of the right eye was normal; the left eye showed mild centraldistortion that extended to the nasal side of the grid. The anterior segmentexam of both eyes was unremarkable.
On dilated fundus exam, the vitreous was clear O.U. The optic nervesappeared
healthy with small cups and good rim color and perfusion in botheyes. The
rest of the fundus exam of the right eye was normal. In the lefteye temporal
to the macula there was a subtle elevation of the pigmentepithelium (see
photo). Also evident was a neurosensory retinal detachmentinvolving the
fovea. In the periphery there were no open holes, tears,breaks or retinal
detachment.
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The left eye exhibited anonpigmented paramacular lesion with an overlying detachment of the neurosensory retina. |
Discussion
The first issue is which test will provide the most useful diagnostic information.Fluorescein angiography will yield some useful information, but the mostimportant test is ultrasonography (echography). In this case it showedhigh internal reflectivity. So, based on the fundus appearance, locationof the lesion and echography results, this patient has a choroidal hemangiomawith an overlying neurosensory retinal detachment.Choroidal hemangioma, or cavernous hemangioma of the choroid, is a benign,developmental tumor that can appear in isolation or associated with Sturge-Webersyndrome. Patients with Sturge-Weber syndrome typically present with angiomatousmalformations of the face (nevus flammeus), uveal tract and brain. Ourpatient had an isolated choroidal hemangioma.
These vascular tumors are composed mostly of large, dilated, thin-walledvessels with minimal stroma. They blend almost imperceptibly with the surroundingchoroidal tissue. Choroidal hemangiomas are usually round or oval, slightlyelevated, with a subtle orange-red color. Often they have indistinct borders.Usually they are most apparent with binocular indirect ophthalmoscopy.Typically you’ll see choroidal hemangiomas in the posterior pole, mostoften within the paramacular area. Some may appear adjacent to the opticnerve or on the nasal side of the disc.
Most patients are asymptomatic, which means you usually discover theselesions incidentally. Symptoms may develop if the lesion is directly underthe macula, or if the patient develops a neurosensory detachment that spreadsfrom the edge of the tumor into the macular area (as in this case).
These tumors generally do not grow much once the patient reaches adulthood.There
may be minor enlargement later in life, perhaps due to varicosityand congestion
of the large vascular channels. Over time, the hemangiomamay cause a degenerative
breakdown of the overlying RPE, resulting in cysticedema or a serous detachment
of the sensory retina.
Fluorescein angiography shows a characteristic pattern of early hyperfluorescencecorresponding
to the large vascular channels in the tumor. Later in theangiogram there
is widespread fluorescence secondary to diffuse leakageof the dye from
the surface of the tumor. A circular zone of hypofluorescencecorresponding
to the edges of the tumor also appears in the early and middlephases of
the angiogram. Finally, the fluorescein pattern will show characteristicpolycystic
degenerative changes and overlying retinal edema.
Problem is, a similar staining pattern shows up in other similar-sizedtumors. That’s why ultrasonography is the most helpful test in differentiatingthese tumors from more serious conditions such as choroidal melanoma. Achoroidal melanoma shows low to medium reflectivity, whereas a choroidalhemangioma demonstrates high reflectivity. Most of all, it’s the reddish-orangecolor of the lesion on BIO that helps differentiate a choroidal hemangiomafrom other light or nonpigmented lesions.
Patients don’t require treatment unless they develop cystoid macularedema or an exudative neurosensory detachment involving the macula. Thesecases call for photocoagulation to the surface of the tumor, hoping tocollapse the cystic retina onto the tumor with subsequent resolution ofthe subretinal fluid.
Our patient had photocoagulation to the surface of the tumor with completeresolution of his neurosensory detachment. His vision returned to 20/25.He went back to playing quarterback but was unable to lead the Dolphinsto the Super Bowl.
1. Gass JDM. Stereoscopic Atlas of Macular Disease: Diagnosis and Treatment.4th edition. St Louis: C.V. Mosby, 1997.top
July 15, 2000