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Year : 2007  |  Volume : 55  |  Issue : 4  |  Page : 298-299

Vitrectomy for circumscribed choroidal hemangioma with exudative retinal detachment refractory to transpupillary thermotherapy

Retina-Vitreous Service, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Submission05-Aug-2006
Date of Acceptance18-Sep-2006

Correspondence Address:
Dhananjay Shukla
Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, 1 Anna Nagar, Madurai - 625 020, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.33044

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We report successful surgical management of a circumscribed choroidal hemangioma with exudative retinal detachment refractory to transpupillary thermotherapy (TTT). A 33-year-old man with symptomatic serous macular detachment in the left eye (Snellen acuity: 20/200) secondary to a paramacular choroidal hemangioma was treated with TTT. The nonresponsive detachment was subsequently managed by vitrectomy, endophotocoagulation and silicon-oil tamponade. It resulted in complete resolution of the tumor and the detachment. Silicon oil was removed at four months. Visual acuity improved to 20/80 by the last follow-up visit at 10 months without any recurrence.

Keywords: Circumscribed choroidal hemangioma, transpupillary thermotherapy, vitrectomy.

How to cite this article:
Shukla D, Ramasamy K. Vitrectomy for circumscribed choroidal hemangioma with exudative retinal detachment refractory to transpupillary thermotherapy. Indian J Ophthalmol 2007;55:298-9

How to cite this URL:
Shukla D, Ramasamy K. Vitrectomy for circumscribed choroidal hemangioma with exudative retinal detachment refractory to transpupillary thermotherapy. Indian J Ophthalmol [serial online] 2007 [cited 2020 Aug 4];55:298-9. Available from: http://www.ijo.in/text.asp?2007/55/4/298/33044

Choroidal hemangioma is a benign vascular tumor that can occur as a circumscribed mass without systemic associations or a diffuse lesion associated with the Sturge-Weber syndrome. [1] Circumscribed choroidal hemangioma (CCH) may cause moderate visual impairment by exudative macular detachment, due to its location in/around the posterior pole. [1],[2] Currently, photodynamic therapy (PDT) and transpupillary thermotherapy (TTT) are the preferred treatment options. [1] We describe a patient who developed a total retinal detachment after TTT for CCH and was successfully treated with vitrectomy and endophotocoagulation. We are not aware of any previous report of significant functional improvement with vitrectomy in a similar condition.

  Case History Top

A 33-year-old man presented with blurred vision in the left eye for three weeks. On examination, best-corrected visual acuity (BCVA) was 20/20 right eye and 20/200 left eye. Left eye fundus revealed a paramacular orange-red subretinal lesion with exudative detachment involving the macula and the lower half of the retina. Ultrasonography showed a localized choroidal thickening with moderate-high internal reflectivity. Fluorescein angiography revealed nonspecific hyperfluorescence, increasing in the late phases. The patient was explained the options of PDT and TTT; he opted for the latter due to financial constraints. TTT was done on a slit-lamp-mounted delivery system (IRIS Medical, Iridex Corp, Mountain View, CA). Threshold power was determined with a nasal test-spot. Using five overlapping 2 mm spots, marginally-suprathreshold burns were delivered (540 mW, 1min), to obtain a faint retinal blanching. A week postTTT, the patient presented with vitreous haze and increased retinal detachment; BCVA had reduced further to 13/200 [Figure - 1]A. The initial management was conservative, with topical/posterior-subtenon corticosteroids. When the detachment persisted for a month, the patient was explained the need for PDT / vitrectomy/referral for radiotherapy elsewhere. The patient preferred vitrectomy, which was performed with endophotocoagulation over the tumor (Frequency-doubled Nd:YAG laser, 250 to 300 mW, 0.1 to 0.15 second, 203 spots) and silicon oil tamponade. Oil was removed after four months. No recurrence/re-detachment was observed till the last visit (10 months); BCVA improved to 20/80 [Figure - 1]B.

  Discussion Top

The decision to treat a CCH should be individualized according to the extent of symptoms, tumor location and visual potential. [1] Though PDT is emerging as the treatment of choice, there is still a place for photocoagulation, TTT and irradiation, depending on the aforementioned parameters. [1],[2] TTT, however, may cause visually significant complications. [3] It is therefore not recommended for subfoveal/juxtafoveal/peripapillary tumors. [1],[2],[3] We experienced worsening of the exudative detachment after TTT for an extrafoveal CCH. The tumor however regressed completely after vitrectomy: endo-drainage of the subretinal fluid facilitated direct photocoagulation of the tumor and silicon oil tamponade probably prevented re-accumulation of the exudative fluid in the immediate postoperative period. The surgery could also have helped by removing the inflammatory mediators. Though others have attempted vitrectomy in extensive detachment with CCH, the aim was to avoid neovascular glaucoma/enucleation, rather than functional improvement. [2] A Japanese study reported recurrence of exudative detachment after vitrectomy for a CCH (subsequently treated with TTT). [4] Our case presents a reverse course of events in context of treatment sequence and results. We removed silicon oil later than they did (four weeks); and did not observe any recurrence for six months subsequently. We propose vitrectomy with endophotocoagulation as a viable alternative in the management of CCH with extensive retinal detachment.

  References Top

Singh AD, Kaiser PK, Sears, JE. Choroidal hemangioma. Ophthalmol Clin North Am 2005;18:151-61.  Back to cited text no. 1
Shields JA, Shields CL, Materin MA, Marr BP, Demirci H, Mashayekhi A. Changing concepts in management of circumscribed choroidal hemangioma: The 2003 J. Howard Stokes Lecture, Part 1. Ophthalmic Surg Lasers Imaging 2004;35:383-94.  Back to cited text no. 2
Gunduz K. Transpupillary thermotherapy in the management of circumscribed choroidal hemangioma. Surv Ophthalmol 2004;49:316-27.  Back to cited text no. 3
Hirakata A, Okada AA, Asakawa M, Mitsui K, Hida T. A case of choroidal hemangioma with bullous exudative retinal detachment treated successfully by transpupillary thermotherapy. Nippon Ganka Gakkai Zasshi 2001;105:415-20.  Back to cited text no. 4


  [Figure - 1]

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3 Authorsę reply [6]
Shukla, D., Kim, R.
Indian Journal of Ophthalmology. 2008; 56(1): 85


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