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PHOTO ESSAY
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 830-831

Bilateral multifocal choroidal osteoma presented with optic disc edema


Department of Ophthalmology, University of Pécs Medical School, Hungary

Date of Submission17-Jul-2021
Date of Acceptance14-Feb-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Eszter Szalai
Department of Ophthalmology, University of Pécs Medical School, Rákóczi u. 2, 7623 Pécs
Hungary
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1922_21

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  Abstract 


Keywords: Choroidal osteoma, multimodal imaging, ocular oncology, optic disc edema


How to cite this article:
Kolkedi Z, Csutak A, Szalai E. Bilateral multifocal choroidal osteoma presented with optic disc edema. Indian J Ophthalmol Case Rep 2022;2:830-1

How to cite this URL:
Kolkedi Z, Csutak A, Szalai E. Bilateral multifocal choroidal osteoma presented with optic disc edema. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 13];2:830-1. Available from: https://www.ijoreports.in/text.asp?2022/2/3/830/351131



Choroidal osteoma is a rare, usually unilateral intraocular bony mass of unknown origin that typically presents in the juxtapapillary or papillomacular region.[1] The differential diagnosis of choroidal osteoma includes benign and malignant tumors, such as amelanotic uveal melanoma, choroidal hemangioma, granuloma, and metastasis.

A 20-year-old male patient was referred to our department with de novo bilateral subretinal masses and optic disc edema. He had a history of recurrent orbital cellulitis on the right side and recurrent episodes of episcleritis/scleritis in both eyes. At 15 years of age, orbital CT and MRI revealed right orbital inflammation; lymphoma, orbital pseudotumor, and granulomatous inflammatory conditions could not be excluded. The patient received systemic steroids and antibiotics at an outside institution which led to the resolution of orbital cellulitis. Subsequent systemic workup (imaging studies, lab, immunology, serology) was negative for malignant, infectious, and immunological diseases. His first examination at our department showed a best-corrected visual acuity (BCVA) of 20/20 in both eyes and an intraocular pressure of 16/16 mmHg. Slit-lamp examination of the anterior segment was unremarkable. There was no evidence of inflammation in the aqueous and vitreous. Dilated fundus examination of both eyes demonstrated optic disc edema and orange-yellowish, well-demarcated dome-shaped mass supero-temporal to the optic disc, multiple flat orange lesions in the right posterior pole, and another smaller lesion in the left fundus [Figure 1]a and [Figure 1]b. On fluorescein angiography, the optic disc was hyperfluorescent and the choroidal lesions showed marked early and late hyperfluorescence [Figure 1]c. Ultrasound examination (Aviso, Quantel Medical, Les Ulis, France) showed hyperreflective signals with acoustic shadowing in both eyes [Figure 1]d. The patient was lost to follow-up for 2 years, during which time he did not experience any ocular or systemic symptoms.
Figure 1: Photography of choroidal osteomas with optic disc edema in the right (a) and left eye (b). Fluorescein angiography indicating hyperfluorescence of the choroidal lesion and the optic disc during the late phase in the right eye (c). Ultrasound examination of the right eye showing two highly reflective signals with acoustic shadowing (d)

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And 2 years later, the patient presented with resolution of the bilateral optic disc edema [Figure 2]a and [Figure 2]b, and his BCVA was 20/20 in both eyes. Swept-source optical coherence tomography (SS-OCT; DRI OCT Triton; Topcon, Tokyo, Japan) revealed choroidal thickening with horizontal lamellar structures resembling bone lamellae; hyperreflective dots and tubules were surrounded by dense areas on OCT angiography [Figure 2]c and [Figure 2]d. The neurosensory retina and retinal pigment epithelium did not show any changes in the macular region even if the larger choroidal mass extended into the submacular space [Figure 2]c. The previously documented choroidal masses showed a mild increase in diameter, but the elevated lesions in both eyes appeared to have decreased in thickness when measured with OCT. Retinal nerve fiber layer thickness was within normal limits in both eyes.
Figure 2: Multiple choroidal osteomas after resolution of optic disc edema in the right (a) and left eye (b). Swept-source optical coherence tomography (SS-OCT) showing horizontal lamellar structures in the choroid extending into the submacular space in the right eye (c), and OCT angiography demonstrating hyperreflective dots and tubular structures with surrounding dense areas in the central part (yellow rectangle) of osteoma (d)

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  Discussion Top


Historically, choroidal osteoma has been characterized as an osseous choristoma, and bone formation was described within the choroidal stroma.[2] However, the precursors and stimuli for ossification remained unclear. Samuels B[3] considered choroidal osteogenesis is a result of intraocular inflammation. Trimble and Schatz[4] reported a young patient with choroidal osteoma, choroiditis, and optic nerve edema highlighting the inflammatory background of the disease. Previous authors reported single choroidal osteoma cases with optic atrophy.[5]

Our patient had extraocular inflammation in his medical history, and he presented with bilateral, multifocal choroidal osteomas and optic disc edema. Shields et al.[5] postulated three possible explanations for choroidal osteoma accompanied by disc edema: compressive (obstruction of venous outflow by the lesion), inflammatory origin, and independent presentation of obstruction and inflammation. Our case supported the inflammatory origin since the retinal nerve fiber layer thickness of both eyes was normal with no evidence of optic atrophy 2 years after the disc edema. Although choroidal osteoma is a benign tumor, it can slowly grow in size, decalcify, and disappear over time; thus, the patient should be frequently monitored with multimodal imaging.

Ethics approval and consent to participate

This case report was granted an exemption by the ethical committee of our institution review board. The patient in the present study has given informed consent to the publication of his case.

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, 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;123:1658-66.  Back to cited text no. 1
    
2.
Williams AT, Font RL, Van Dyk HJ, Riekhof FT. Osseous choristoma of the choroid simulating a choroidal melanoma. Association with a positive 32P test. Arch Ophthalmol 1978;96:1874-7.  Back to cited text no. 2
    
3.
Samuels B. Ossification of the choroid. Trans Am Acad Ophthalmol Otolaryngol 1938;43:193.  Back to cited text no. 3
    
4.
Trimble SN, Schatz H. Choroidal osteoma after intraocular inflammation. Am J Ophthalmol 1983;96:759-64.  Back to cited text no. 4
    
5.
Shields JA, Shields CL, Ellis J, Depotter P. Bilateral choroidal osteoma associated with bilateral total blindness. Retina 1996;16:445-7.  Back to cited text no. 5
    


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