History of present illness
An otherwise healthy 5-year-old female patient was referred to our retina division for a lesion that was noted temporal to the macula in the right eye. According to the patient’s mother, the patient had been visually asymptomatic. There was no medical history of trauma, cancer, infectious, inflammatory, or autoimmune conditions. Her past surgical history and family history were unremarkable. She had no known drug allergies and was not taking any medications. Reviews of systems were also unremarkable.
Questions to ask
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What is the ocular examination’s result?
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What is the result of spectral-domain optical coherence tomography (SD-OCT) and B-scan?
Assessment
On ocular examination, the best-corrected visual acuity was 20/30 in both eyes without any elements of amblyopia. Extraocular movements were intact, and the pupils were round and reactive, without any relative afferent pupillary defect. Anterior and posterior segment examination was unremarkable. Vitreous cavity was quiet. Fundus examination revealed a yellowish-orange oval choroidal lesion temporal to the macula in the right eye, approximately 3.5 mm in maximum diameter, with well-delineated margins ( Fig. 63.1 ). No feeder vessels were observed, and no cells were seen in the vitreous cavity.
Differential diagnosis
The differential diagnosis for lesions in the choroid containing calcium includes choroidal osteoma, retinoblastoma, choroidal calcified granuloma, astrocytic hamartoma (astrocytoma), idiopathic sclerochoroidal calcification, and retinal intraocular foreign body.
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Flowcharting (see Fig. 63.2 )
Fig. 63.2
Optical coherence tomography: no subretinal fluid or choroidal neovascularization. Echography: flat lesion containing calcification with high-intensity echoes from the inner surface of the lesion and posterior shadowing.
Algorithm 63.1 : Algorithm for calcified choroidal lesion in a young girl.ar histoplasmosis syndrome
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Multimodal testing and results: less and more severe variations and working diagnosis
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Ultrasound B-scan assessment showed a flat choroidal lesion containing calcification suggested by high-intensity echoes with posterior shadowing. OCT imaging did not reveal any evidence of subretinal fluid or choroidal neovascularization (CNV) ( Fig. 63.2 ). The fellow eye was normal. An examination under anesthesia showed no additional abnormalities. Given the clinical findings, the patient was diagnosed with a choroidal osteoma, and observation was recommended.
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Choroidal osteoma is a benign, rare, and classically unilateral tumor that can cause vision-threatening complications after tumor growth, decalcification, and through development of CNV. , Eyes with extrafoveal choroidal osteoma often maintain good visual acuity, but those osteomas affecting the macula can produce significant visual loss. This may be caused by retinal pigment epithelial and photoreceptor atrophy, the presence of serous subretinal fluid, and/or development of CNV associated with the lesion. ,
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Although photodynamic therapy (PDT) has been reported to be effective in achieving regression of the mass in some cases, decalcification may be complicated by secondary CNV, necessitating close monitoring in these patients.
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