Reduced fluence photodynamic therapy for subretinal fluid in choroidal nevus

Harpreet K Narde; Ananya Goswami; Vimal Vashistha; Atul Kumar

doi:10.4103/ijo.IJO_1303_21

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 2 | Page : 475-477

Reduced fluence photodynamic therapy for subretinal fluid in choroidal nevus

Harpreet K Narde, Ananya Goswami, Vimal Vashistha, Atul Kumar
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India

Date of Submission	19-May-2021
Date of Acceptance	04-Oct-2021
Date of Web Publication	13-Apr-2022

Correspondence Address:
Atul Kumar
Retina Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1303_21

Abstract

Choroidal nevus is a benign melanocytic lesion of the posterior uvea. Visual symptoms in choroidal nevus are most commonly secondary to serous neurosensory detachment in upto 50% cases. Here, we describe a case of symptomatic perifoveal Choroidal Nevus with sub-retinal fluid, which was treated with Reduced Fluence Photodynamic Therapy.

Keywords: Fundus fluorescein angiography, Neurosensory detachment, Reduced fluence photodynamic therapy, Subretinal fluid, Swept-source optical coherence tomography

How to cite this article:
Narde HK, Goswami A, Vashistha V, Kumar A. Reduced fluence photodynamic therapy for subretinal fluid in choroidal nevus. Indian J Ophthalmol Case Rep 2022;2:475-7

How to cite this URL:
Narde HK, Goswami A, Vashistha V, Kumar A. Reduced fluence photodynamic therapy for subretinal fluid in choroidal nevus. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 18];2:475-7. Available from: https://www.ijoreports.in/text.asp?2022/2/2/475/342878

A Choroidal nevus can become symptomatic when associated with serous neurosensory detachment, sub-retinal choroidal neovascular membrane, or photoreceptor degeneration. Presence of sub-retinal fluid does not inevitably indicate progression to melanoma and can be associated with a benign Choroidal nevus. Treatment modalities for sub-retinal fluid in choroidal nevus can be Laser photocoagulation, Transpupillary thermotherapy, Photodynamic therapy, or anti-VEGF therapy. However, laser and transpupillary thermotherapy might lead to visual damage when used in perifoveal location. This case report describes the treatment of sub-retinal fluid associated with a perifoveal Choroidal nevus by utilizing Reduced Fluence Photodynamic therapy (rf-PDT).

Case Report

A 26-year-old female patient presented with complaints of central scotoma with distortion of vision in the left eye for the past 1 month. The patient's past medical history was unremarkable. Best corrected visual acuity was 20/20 in right eye and 20/30 in left eye. Intraocular pressure was within normal limit in both eyes. Anterior segment examination of both eyes was normal. Fundus examination of the right eye was unremarkable. Fundus examination of the left eye showed a discrete, flat, and homogenously pigmented choroidal lesion with overlying drusens, of size 2 disc diameters (DD), located temporal to fovea [Figure 1]a. Swept-source optical coherence tomography (Triton™, Topcon) of the left eye revealed a peri-foveal, hyper-reflective, choroidal lesion with gradation of reflectivity from inner to outer choroid and hypo-reflective shadowing. Serous neurosensory detachment (NSD) was noted overlying the choroidal lesion with thickened outer retinal layers and elongated 'shaggy' photoreceptors [Figure 1]b and [Figure 2]a. On fundus fluorescein angiography (FFA, Optos california) of left eye [Figure 1]c, there was focal pinpoint hyperfluorescence in the early phase, located temporal to the fovea. ICG angiography [Figure 1]d revealed a hypocyanescent choroidal lesion. No abnormal vascularization was present. Ultrasound B-scan OS revealed a flat echogenic mass lesion measuring 3.85-mm base diameter and 0.85-mm thickness [Figure 3]. Applying the mnemonic of TFSOM-UHHD given by Shields et al., 2 criteria (F: Fluid, S: Symtoms) were met. This weighed towards the diagnosis of choroidal nevus as against a small choroidal melanoma.

Figure 1: (a) Fundus image (Optos) of left eye showing choroidal nevus located temporal to fovea. (b) Swept-source Optical Coherence Tomography image of left eye showing choroidal nevus with overlying sub-retinal fluid and 'shaggy' photoreceptors (arrow). (c) Fluorescein angiography of left eye showing focal pinpoint hyperfluorescence in the area of choroidal nevus. (d) Indocyanine angiography of left eye showing hypocyanescent choroidal lesion with no abnormal vascularisation

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Figure 2: (a) Baseline SSOCT of left eye showing choroidal nevus with overlying neurosensory detachment. (b) SSOCT of left eye showing resolution of neurosensory detachment with persistent thickening of outer retinal layers at 6 weeks post rf-PDT. (c) SS-OCT of left eye showing complete resolution of peri-foveal, sub-retinal fluid with improved contour of outer retinal layers at 3 months post rf-PDT

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Figure 3: Ultrasound B-scan OS revealed a flat echogenic mass lesion measuring 3.85-mm base diameter and 0.85-mm thickness

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A diagnosis of left eye choroidal nevus with sub-retinal fluid was made. The rf-PDT (Fluence: 25 J/cm2) was done for this juxtafoveal choroidal nevus, sparing the fovea. A single intravenous dose of verteporfin 6 mg/m2 (Visudyne, OLT Ophthalmics, CA) was infused. Diode laser 689 nm at reduced fluence (25 J/cm2) was applied to the greatest linear diameter (GLD) of choroidal nevus, measuring 1702 m (measured on ICG-Angiography) for 83 seconds.

At 6 weeks' follow-up, patient recovered BCVA of 20/20 in the left eye with disappearance of central scotoma and subjective improvement of distorted vision. Swept-Source Optical Coherence Tomography (SSOCT) showed resolution of neurosensory detachment with persistent thickening of outer retinal layers [Figure 2]b. Size of choroidal nevus remained unchanged. However, pinpoint hyper-fluorescence disappeared on fluorescein angiography [Figure 4].

Figure 4: (a) Baseline FFA of left eye showing focal pinpoint hyperfluorescence in the area of choroidal nevus. (b) FFA of left eye at 6 weeks showing resolution of hyperfluorescence

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At 3-months' follow-up, patient maintained BCVA of 20/20 in the left eye. SS-OCT showed complete resolution of peri-foveal, sub-retinal fluid with improved contour of outer retinal layers [Figure 2]c.

Discussion

Choroidal nevus is a benign melanocytic lesion of the posterior uvea, often incidentally diagnosed on fundus evaluation. However, a choroidal nevus may become symptomatic if associated with serous neurosensory detachment, sub-retinal choroidal neovascular membrane or photoreceptor degeneration. The decreased visual acuity in choroidal nevus is most commonly secondary to serous foveal detachment in upto 50% cases.^[1] Such cases mimic Acute Central Serous Chorioretinopathy clinically and on fluorescein angiography. The sub-retinal fluid possibly arises due to compression of choriocapillaries, which increases intravascular hydrostatic pressure near the choroidal nevus.^[2] This pressure gradient then transudates fluid through micro-breaks in retinal pigment epithelium, close to the tumor surface. These pinpoint areas of leakage clinically presents as sub-retinal fluid.^[3] In contrast to CSCR, a spontaneous resolution may not be the usual scenario, as mechanical compression due to tumor growth is responsible for the increased hydrostatic pressure in choroidal vessels.

Photodynamic therapy has been utilized in ocular oncology to achieve destruction of the tumor tissue. Response to photodynamic therapy is thought to be caused by a series of events including vasoconstriction, thrombosis, destruction of abnormal vessels, and hypoxia.^[4] For Choroidal nevus, the goal of treatment is to achieve symptomatic improvement without compromising vision, and not complete tumor regression.^[5] Hence, a reduced fluence of 25 J/cm2 was used for photodynamic therapy. Alternately, a focal laser with 577-nm yellow laser or frequency doubled Nd-yag laser can be used. Photodynamic therapy is especially useful for subfoveal and juxtafoveal lesions. No complications were seen including RPE atrophy, RPE tear or fibrosis, choroidal ischemia, and sub-retinal hemorrhage.^[6],[7] However, the possibility of recurrence of subretinal fluid cannot be precluded.

Conclusion

Reduced fluence photodynamic therapy (rf-PDT) can provide safe and effective symptomatic treatment for sub-retinal fluid associated with choroidal nevus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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