|LETTER TO EDITOR
|Year : 2008 | Volume
| Issue : 1 | Page : 85
Dhananjay Shukla, Ramasamy Kim
Retina-Vitreous Service, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
|Date of Web Publication||21-Dec-2007|
Retina-Vitreous Service, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shukla D, Kim R. Authors' reply. Indian J Ophthalmol 2008;56:85
We thank Rishi et al. for creating the opportunity to extend the discussion on the management options for circumscribed choroidal hemangioma (CCH). The question raised is "Why was transpupillary thermotherapy (TTT) not attempted again after the initial failure, as successfully done by them as well as by Garcia-Arumi et al.?"
To respond to the query: we neither practice nor are aware of any report (including Garcia-Arumi's) that recommends re-treatment in CCH or for that matter, any pathology, with a treatment modality that causes significant and persistent worsening of both functional and anatomical status after the first attempt. The increased retinal detachment (RD) with 2-line drop in vision was managed conservatively for a month without success, after which we offered photodynamic therapy, a safer and more effective alternative, as one of the options; withholding the offending initial treatment. The tumor in our patient was 3.2-mm thick, with a base diameter of 6.0 mm.
Garcia-Arumi et al. did report a modest post-TTT increase in RD in three cases. However, they also mentioned that it subsided spontaneously in each case within two to three weeks. Their indication for re-treatment was incomplete re-absorption of fluid; not a worsening of preexisting RD, as happened in our case. Therefore, we can't derive treatment guidelines from their experience. In fact, the status of our patient's eye one month after TTT (total RD) fitted into Garcia-Arumi's exclusion criteria for TTT.
The case described by Rishi et al. fits into Garcia-Arumi's exclusion criteria for TTT: total bullous RD, with tumor height >3.5 mm. They must be congratulated for their successful outcome, which extends the scope of TTT. However, neither of these two reports constitutes a standard-of-care treatment recommendation for CCH, for which, treatment must be individualized as per the situation at hand, as we mentioned in the first line under discussion. Additionally, we note with surprise that this letter reports a dramatically improved visual outcome of 20/40 at three-year follow-up in contrast to the poor visual recovery (10/200) stable for 10 months after TTT in the published report, which explained the poor outcome by subfoveal tumor location.
We reported a new modality for successful treatment of CCH refractory to TTT, which adds to the armamentarium of existing treatment options. We reiterate that we do not recommend re-treatment of CCH with TTT when it results in significant aggravation of the pre-treatment status.
| References|| |
Rishi P, Sharma T. Transpupillary thermotherapy for large-sized subfoveal circumscribed choroidal haemangioma. Retina 2006;26:974-6.
Garcia-Arumi J, Ramsay LS, Guraya BC. Therapeutic options for capillary papillary hemangiomas. Ophthalmology 2000;107:48-54.
Shukla D, Ramasamy K. Vitrectomy for circumscribed choroidal hemangioma with exudative retinal detachment refractory to transpupillary thermotherapy. Indian J Ophthalmol 2007;55:298-9.