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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 780-782

Choroidal hemangioma in pregnancy and post-partum: A case report


Shmuel Bait 12, Jerusalem, Israel

Date of Submission11-Nov-2021
Date of Acceptance26-May-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Aleza A Andron
Shmuel Bait 12 Jerusalem – 9103102
Israel
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2826_21

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  Abstract 


To report a patient with choroidal hemangioma (CH) presenting in the third trimester of pregnancy, with visual symptoms and subretinal fluid. A 42-year-old 30-week pregnant woman presented to the ocular oncology service, with new-onset visual deterioration in her right eye. Fundoscopy revealed an orange elevated choroidal lesion in the macular region, with overlying subretinal fluid. The working diagnosis was a CH and a decision was made to monitor the patient until after delivery. Post-partum, the patient reported improvement in symptoms, and on examination, spontaneous resolution of the subretinal fluid was noticed, demonstrated also on optical coherence tomography (OCT). CH is a potentially sight-threatening lesion that may exacerbate during pregnancy. A watchful waiting approach should be considered, as a spontaneous resolution of subretinal fluid may occur after delivery.

Keywords: Choroidal hemangioma, hamartoma, pregnancy, sub-retinal fluid


How to cite this article:
Andron AA, Fabian ID, Vishnevskia-Dai V. Choroidal hemangioma in pregnancy and post-partum: A case report. Indian J Ophthalmol Case Rep 2022;2:780-2

How to cite this URL:
Andron AA, Fabian ID, Vishnevskia-Dai V. Choroidal hemangioma in pregnancy and post-partum: A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 11];2:780-2. Available from: https://www.ijoreports.in/text.asp?2022/2/3/780/351154



Choroidal hemangioma (CH) is a vascular hamartoma that can be congenital and present at birth.[1] The majority of patients present in the fourth to sixth decades with a predominant male predilection.[1],[2] CH may cause visual deterioration due to subretinal fluid leakage. If asymptomatic observation is an acceptable treatment. The goal of treatment is to decrease the subretinal macular fluid and restore vision.[3] Accepted treatments include laser photocoagulation, transpupillary thermotherapy, photodynamic therapy with verteporfin, and radiation therapy.[4],[5],[6],[7] Anti Vascular endothelial growth factor (VEGF) can also be given to resorb subretinal fluid as an adjuvant to the aforementioned therapies.[6] Several reports have pointed out the possible association between pregnancy and excess subretinal leakage from CH.[6],[7]


  Case Report Top


A 40-year-old 30-week pregnant woman presented to the ocular oncology service at Sheba Medical Center, with new-onset visual deterioration in her right eye. She reported no past ocular or systemic history. The left eye was normal with 20/20 visual acuity (VA). On right eye examination, VA was 20/40 anterior segment was normal, and fundoscopy revealed an orange elevated choroidal lesion in the macular region, with overlying subretinal fluid [Figure 1]. B-scan ultrasound demonstrated a hyperechoic choroidal lesion, the dimensions of which were 4.91–6.61 mm in base diameter and 1.86 mm in elevation [Figure 2]. A-scan found the lesion to have medium–high internal reflectivity [Figure 3], and optical coherence tomography (OCT) showed a shallow retinal detachment overlying the lesion [Figure 4].
Figure 1: Fundus photograph: orange elevated choroidal lesion

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Figure 2: Ultrasound B scan: hyperechoic choroidal lesion measuring 1.86 mm in height and 6.61 mm in diameter

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Figure 3: Ultrasound A scan: high internal reflectivity

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Figure 4: OCT showing shallow retinal detachment upon presentation

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In light of the presentation and no history of other primary malignancy, the working diagnosis was a CH and a decision was made to monitor the patient with no further investigations or interventions until after delivery. The patient was seen once again at week 35 of pregnancy, with no significant change in her systemic or ocular condition.

On a follow-up visit, 5 days after delivery, the patient reported improvement in symptoms.

On examination, spontaneous resolution of the subretinal fluid was noticed and demonstrated also on OCT [Figure 5].
Figure 5: OCT 4 days post-partum showing improvement in subretinal fluid

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At the final visit of 4 months, post-partum VA was 20/25, and a pink amelanotic lesion was seen on fundoscopy with no underlying fluid. B scan showed a slight decrease in the height and diameter of the lesion. OCT was performed and revealed no recurrence of subretinal fluid [Figure 6].
Figure 6: OCT 3 months post-partum showing full resolution of subretinal fluid

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  Discussion Top


CH is a rare benign choroidal tumor. The true incidence is unknown, as most cases are discovered if symptomatic or after one routine fundoscopic examination. In most series it is found that 50% of CHs are diffuse type and associated with Sturge‒ Weber syndrome More Details and 50% are circumscribed CH. According to Shields et al., the most common tumor location is posterior, temporal to the optic disk; with 67% of tumors found in the macula, 34% between the macula and the equator, and no tumors seen anterior to the equator. According to Krohn, the mean tumor basal diameter was 7.2 mm, whereas the mean tumor height was 2.4 mm. In this study, subretinal fluid was present in 67% and cystoid macular edema in 42%, with sub-retinal fluid exudation associated with younger age.

In our case, the tumor location was macular 4.91–6.61 mm in base diameter and 1.86 mm in elevation with Subretinal fluid (SRF) exudation. There are only a few case reports of CHs presenting at pregnancy with spontaneous regression after delivery,[5],[6],[7] thus little is understood about their behavior. Amelanotic choroidal lesions with subretinal fluid can present a diagnostic dilemma as some diagnostic aids such as fluorescein angiography are not routinely performed during pregnancy.[8] In addition, treatment is problematic because Photodynamic therapy (PDT) with verteporfin is considered class C and therefore is not routinely used in pregnancy. In our case, due to a high index of suspicion of the diagnosis and the uncertainty of diagnostic testing during pregnancy, we decided not to perform ancillary testing and observe closely until delivery, and then treat if necessary. Upon delivery, there was spontaneous regression of the SRF and recovery of VA.

Based on previous reports and our observation, we propose that exacerbation of CH can occur in pregnancy as a result of a few mechanisms. There is increased plasma volume in pregnancy, which can produce leakage from blood vessels as is evident in edema in the legs in the third trimester.[9] The hormone relaxin is produced in excess in pregnancy, which causes vasodilation and aid in this leakage of fluid.[10] Perhaps VEGF plays a role as well as it is increased in pregnancy and can cause increased angiogenesis with enlargement of the hemangioma.[9] Due to these proposed mechanisms, the resolution of symptoms and subretinal fluid post-partum is logical, supporting watchful observation until delivery.


  Conclusion Top


CH is a potentially sight-threatening lesion that may exacerbate during pregnancy. A watchful waiting approach should be considered, as a spontaneous resolution of the subretinal fluid may occur after delivery.

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 Top

1.
Shields CL, Honavar SG, Shields JA, Cater J, Demirci H. Circumscribed choroidal hemangioma: Clinical manifestations and factors predictive of visual outcome in 200 consecutive cases. Ophthalmology 2001;108:2237-48.  Back to cited text no. 1
    
2.
Gunduz K. Transpupillary thermotherapy in the management of circumscribed choroidal hemangioma. Surv Ophthalmol 2004;49:316-26.  Back to cited text no. 2
    
3.
Krohn J, Rishi P, Frøystein T, Singh AD. Circumscribed choroidal haemangioma: Clinical and topographical features. Br J Ophthalmo 2019;103:1448-52.  Back to cited text no. 3
    
4.
Kivelä T, Tenhunen M, Joensuu T, Tommila P, Joensuu H, Kouri M. Stereotactic radiotherapy of symptomatic circumscribed choroidal hemangiomas. Ophthalmology 2003;110:1977-82.  Back to cited text no. 4
    
5.
Pitta C, Bergen R. Littwin Spontaneous regression of a choroidal hemangioma following pregnancy. Ann Ophthalmol 1979;11:772-4.  Back to cited text no. 5
    
6.
Sayman Muslubas I, Arf S, Hocaoglu M, Ozdemir H, Karacorlu M. Spontaneous regression of serous retinal detachment associated with circumscribed choroidal hemangioma after childbirth. Retin Cases Brief Rep 2017;11:7-11.  Back to cited text no. 6
    
7.
Cohen VM, Rundle PA, Rennie IG. Choroidal hemangiomas with exudative retinal detachments during pregnancy. Arch Ophthalmol 2002;120:862-4.  Back to cited text no. 7
    
8.
Halperin LS, Olk RJ, Soubrane G, Coscas G. Safety of fluorescein angiography during pregnancy. Am J Ophthalmol 1990;109:563-6.  Back to cited text no. 8
    
9.
Ortega MA, Saez MÁ, Asúnsolo Á, Romero B, Bravo C, Coca S, et al. Upregulation of VEGF and PEDF in placentas of women with lower extremity venous insufficiency during pregnancy and its implication in villous calcification. Biomed Res Int 2019;2019:5320902.  Back to cited text no. 9
    
10.
Martin B, Romero G, Salama G. Cardioprotective actions of relaxin. Cell Endocrinol 2019;487:45-53.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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