|Year : 2022 | Volume
| Issue : 3 | Page : 727-728
Commentary: Torpedo maculopathy: An enigma in the posterior pole of the eye
Piyush Kohli1, Chitaranjan Mishra2
1 Department of Vitreo-Retinal Services, C.L. Gupta Eye Institute, Moradabad, Uttar Pradesh, India
2 Department of Vitreo-Retinal Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
|Date of Web Publication||16-Jul-2022|
Dr. Chitaranjan Mishra
Department of Vitreo-Retinal Services, Aravind Eye Hospital, Anna Nagar, Madurai, Tamil Nadu - 625 020
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kohli P, Mishra C. Commentary: Torpedo maculopathy: An enigma in the posterior pole of the eye. Indian J Ophthalmol Case Rep 2022;2:727-8
Torpedo maculopathy (TM) presents as an asymptomatic, solitary, oval, flat, sharply circumscribed, hypopigmented lesion located along the horizontal axis in the temporal macula with its apex oriented towards the fovea. It usually measures around 2–3 mm horizontally and 1 mm vertically. It was first described in 1971 as “retinal albinotic spots”. Roseman and Gass later termed the lesion as “hypopigmented nevus of the retinal pigment epithelium (RPE)”. Finally, Mark J Daily introduced the term “Torpedo maculopathy” in 1993 considering the unique shape of the lesion.
The diagnosis of TM is usually clinical and based on its typical clinical features. The typical optical coherence tomography (OCT) findings include outer retinal disruption and hyperreflectivity of the RPE and choroid. Wong et al. proposed a binary OCT classification. Type 1 TM is characterized by an attenuation of the interdigitation zone (IZ) and ellipsoid zone (EZ) but doesn't have outer retinal cavitation. On the other hand, type 2 TM is characterized by a definite loss of EZ and IZ, thinning of the outer nuclear layer, and cavitation in the outer retinal layers. Fundus autofluorescence (FAF) shows decreased autofluorescence over the lesion, while the surrounding rim may show increased autofluorescence. Fundus fluorescein angiography (FFA) shows transmission hyperfluorescence without leakage and occasional hyperfluorescence along the margins of the lesion. B-scan ultrasonography indicates a flat lesion. Several studies evaluating the visual field and microperimetry have shown variable results.
We congratulate the authors for reporting a rare case of double TM. Several other variations of TM have been reported earlier as well. Hugo et al. reported two smaller satellite lesions temporal to the main torpedo lesion. All these lesions were hypoautofluorescent and had a hyperautofluorescent temporal tip. Raju et al. reported the presence of two parallel hypopigmented torpedo lesions. The superior torpedo lesion showed a type 1 morphologic pattern while the inferior one showed a type 2 pattern on OCT. Golchet et al. reported multiple variations of TM. These included a small hypopigmented spot temporal to the classic TM; a grossly hypopigmented lesion such that the deeper choroidal vessels and the sclera could be visualized; and hyperpigmentation extending for nearly half the lesion. Ranjith et al. reported a globally hyperpigmented torpedo lesion. Rohl et al. reported hyperpigmented TM surrounded by a halo of patchy hypopigmentation which progressed over the next five years as its size in the vertical axis and the surrounding rim of hypopigmentation increased. Hence, they proposed that TM may be more dynamic than earlier believed. Turkoglu et al. reported a child with retinoblastoma in one eye and a torpedo lesion in the other. They proposed that TM may resemble a tiny retinoblastoma and hand held OCT can help differentiate between the two.
Tripathi et al. reported the presence of a nonconforming focal choroidal excavation on OCT in the tail region of the torpedo lesion. They proposed that this morphology could represent a type 3 pattern. Light et al. reported TM with a long tail or multiple satellite lesions along its tail. OCT showed two patterns in the same lesion. While the foveal portion showed loss of the EZ with no outer retinal cavitation, the temporal tail showed subtle inner choroidal excavation with an intact ellipsoid zone. They proposed that multiple OCT morphologic subtypes can coexist in different geographic areas of the same lesion. They further proposed that morphology could represent a type 4 pattern. Lambert et al. reported TM with a subretinal vitelliform material. OCT showed large subretinal hyperreflective deposits while FAF showed hyperautofluorescence. Choroidal neovascularization (CNVM) has also been reported to be associated with TM. It usually shows a good response to treatment with intravitreal antivascular endothelial growth factor injection.
TM needs to be differentiated from similar lesions like congenital hypertrophy of the RPE (CHRPE) and CHRPE associated with Gardner's syndrome. CHRPE is a flat RPE pigmented or non-pigmented lesion with rounded or scalloped margins and located near or anterior to the equator. These lesions are generally solitary but may occur in clusters, appearing like “bear tracks” or “polar bear tracks”, in case of depigmented spots. Its OCT features include retinal thinning, disorganized retinal anatomy, photoreceptor loss, increased RPE thickness, and decreased reflectivity of the choroid. The lesions associated with familial adenomatous polyposis and Gardner's syndrome are morphologically similar to TM. However, they are usually bilateral, multiple, smaller (<1 mm), irregular in shape, and have a random distribution in the mid-periphery. It is important to know about the several variations of TM and differentiate them from other conditions. While TM is mostly an innocuous condition, other pathologies may be associated with malignant systemic disorders.
TM is a rare and poorly understood condition. Further studies are needed to understand the other clinical and OCT variations of TM. Longitudinal studies can help us understand the progression of these lesions over time.
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