Purpose
To evaluate the efficacy and safety of photodynamic therapy (PDT) for macular circumscribed choroidal hemangioma in Chinese patients.
Design
Retrospective, consecutive, noncomparative case series.
Methods
Twenty-five eyes (25 patients) with macular circumscribed choroidal hemangioma, 18 subfoveal and 7 perifoveal, with vision impairment attributable to subfoveal fluid and retinal detachment underwent visual acuity testing, fundus fluorescein angiography, ultrasonography, and optical coherence tomography (OCT) examinations to evaluate the efficacy and safety of PDT treatment. PDT was performed with a standard concentration of verteporfin and intravenous injection time. Laser was used at 50 J/cm 2 for 83 seconds on subfoveal and 75 J/cm 2 for 125 seconds on perifoveal lesions. More than 1 spot was used for large lesions and spots overlapped only outside the fovea.
Results
The mean follow-up time was 35.5 ± 15 months. All patients were treated with 1 session except in 2 subfoveal cases. The mean best-corrected visual acuity (BCVA) increased from 0.09 ± 0.11 to 0.31 ± 0.37 ( P < .01) and 11 patients (44%) had their vision improve over 4 lines. The remaining 14 patients (56%) had stabilized vision with the retina reattached. The mean thickness of the hemangioma before the treatment was 3.2 ± 0.9 mm and decreased to 1.3 ± 1.0 mm post treatment ( P < .01), with complete regression of tumor in 7 cases (28%).
Conclusions
PDT with individualized laser parameters for macular circumscribed choroidal hemangioma is effective and safe, leading to improved or stabilized BCVA as a result of tumor shrinkage and the resolution of the subretinal fluid.
Circumscribed choroidal hemangioma is one form of choroidal vascular tumor that typically presents in the macular and peripapillary area. Although it is a benign tumor, exudation from the lesion can sometimes lead to retinal detachment, cystoid macular edema, and retinal pigment epithelium (RPE) alterations. It is not rare to see total retinal detachment and visual loss in patients with choroidal hemangioma. Multiple technical approaches are available for choroidal hemangioma, including laser coagulation, cryotherapy, external beam radiation, and transpupillary thermotherapy. While many of these approaches are successful for extramacular lesions, treatment of macular lesions is more problematic as irreversible foveal damage may often occur following treatment. Therefore, photodynamic therapy (PDT) has been advocated for patients with circumscribed macular choroidal hemangioma.
In this study, we evaluate the effectiveness of the PDT in circumscribed macular choroidal hemangioma with exudative retinal detachment in a group of Chinese patients.
Materials and Methods
For this retrospective study, data from a consecutive series of patients receiving treatment with PDT for circumscribed macular choroidal hemangioma at the Eye and ENT Hospital, Fudan University, Shanghai, were collected. Twenty-five eyes of 25 patients diagnosed with symptomatic macular circumscribed choroidal hemangioma between March 2004 and December 2007 were included. Diagnosis of macular circumscribed choroidal hemangioma was made by clinical examination, fluorescein angiography, and B-scan ultrasonography. None of the patients in the study had received prior treatment for choroidal hemangioma.
Assessment of all patients included dilated stereoscopic evaluation of the fundus with a 120-diopter lens, color photography with a 45-degree field, fluorescein angiography, B-scan ultrasonography, and optical coherence tomography (OCT) (Stratus OCT; Carl Zeiss Meditec, Dublin, California, USA). Fluorescein angiographic images were obtained using Zeiss (Carl Zeiss Meditec) or Topcon (Topcon Corporation, Tokyo, Japan) imaging systems to evaluate abnormal vascular perfusion, vascular leakage, and the size of the choroidal hemangioma at the baseline and at 3, 6, and 12 months post treatment, or when recurrence of subretinal fluid was suspected during the follow-up. B-scan imaging was used to evaluate the thickness of the lesions and the elevation of serous retinal detachment in extrafoveal regions (usually inferiorly), both before and after treatment at each patient visit. OCT was also used both before and after treatment for the evaluation of subretinal fluid absorption or recurrence, and for the assessment of the foveal depression and cystoid macular edema.
Following informed consent, PDT was performed using a laser (Opal photoactivator; Lumenis, Beijing, China) emitting light at 698 nm for photosensitization and using verteporfin (Visudyne, Novartis Ophthalmics AG, Basel, Switzerland) administered at 6 mg/m 2 body surface area. Verteporfin infusion was carried out over a 10-minute period under the control of an injection pump (Syringe Pump SP6000, Arcomed AG, Regensdorf, Switzerland). Light exposure was commenced 15 minutes after the beginning of intravenous infusion according to standard PDT protocols. The diameter of the treatment spot was 2.0-5.4 mm; 1 or 2 spots were applied according to the size and shape of the choroidal hemangioma as indicated on fluorescein angiography. The spots were overlapped only outside the fovea and the optic disc was avoided. Treatment parameters of 689 nm at 50 J/cm 2 , with an exposure time of 83 seconds, were applied to subfoveal lesions; for extrafoveal lesions, 75 J/cm 2 , with an exposure time of 125 seconds, was used. Visual acuity and the lesion thickness were also taken into consideration when determining treatment parameters: for patients with a subfoveal tumor greater than 3 mm in thickness and decimal visual acuity less than 0.05, the power of the laser used in the treatment was 75 J/cm 2 over 125 seconds. Retreatment was performed in patients with reduction of visual acuity, accompanied by leakage on fluorescein angiography and the presence of intraretinal and subretinal fluid on OCT. All patients were examined at baseline and then at 1 month post treatment, with follow-up every 3 months subsequently, for a minimum of 12 months. The mean follow-up period was 35 ± 15months (range 12–60 months).
Changes in best-corrected visual acuity (BCVA) and the thickness of choroidal hemangioma were analyzed using paired t test with 95% confidence intervals. P values < .05 were considered statistically significant. Statistical analysis was performed using commercially available software (SPSS software for Windows, Version 16.0; SPSS Inc, Chicago, Illinois, USA).
Results
Twenty-five patients (17 male and 8 female) aged 35 to 55 years (mean 41 ± 7.8 years) were included in this study ( Table ). Presenting symptoms included metamorphopsia and blurring of vision for 1 to 60 months prior to attending the clinic. Prior to the treatment, the mean decimal BCVA was 0.09 ± 0.11 (0.01-0.5). All the patients had evidence of exudative retinal detachment involving the macula; 13 patients had associated cystoid macular edema and macular pigment alterations attributable to longstanding symptoms (>12 months). In 7 cases the hemangioma was extrafoveal, while in 18 cases the lesions were subfoveal. Additional peripapillary involvement was seen in 10 patients. Before treatment, the mean thickness of the tumor was 3.2 ± 0.9 mm (1.6-4.8 mm) and the mean greatest linear dimension was 7.9 ± 1.1 mm (5.8-10.1 mm). Serous retinal detachment outside the fovea was present in all cases, which was demonstrated by B-scan ultrasonography (0.5-4 mm). On fluorescein angiography, the abnormal, large tumor vessels were visualized in the early phase and diffuse, intense hyperfluorescence in the late phase. In each case, the macula was partially or completely involved and demonstrated cystoid edema.
| Case No. | Age (Years) | Gender | Symptom Duration (Months) | Tumor Location | Follow-up (Months) | Initial Decimal BCVA | Final Decimal BCVA | Initial Tumor Thickness (mm) | Tumor Thickness 1 Month Following PDT (mm) | Final Tumor Thickness (mm) | Initial Tumor GLD (mm) | Final Tumor GLD (mm) | No. of PDT Sessions | PDT Parameters (Power/cm 2 /Seconds) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 32 | M | 12 | Subfoveal | 60 | 0.12 | 0.3 | 3.6 | 2.4 | 1.3 | 8.7 | 8.6 | 1 | 50 J/cm 2 /125s |
| 2 | 36 | M | 1 | Perifoveal | 60 | 0.05 | 1.2 | 1.7 | 1.0 | 0 | 8.4 | 0 | 1 | 75 J/cm 2 /125s |
| 3 | 40 | M | 24 | Subfoveal | 60 | 0.03 | 0.02 | 3 | 0 | 0 | 8.0 | 0 | 1 | 75 J/cm 2 /125s |
| 4 | 32 | M | 12 | Subfoveal | 60 | 0.01 | 0.03 | 4.8 | 2.3 | 1.9 | 8.1 | 6.3 | 1 | 75 J/cm 2 /125s |
| 5 | 40 | F | 12 | Subfoveal | 48 | 0.05 | 0.5 | 3.3 | 2.58 | 1.9 | 8.2 | 5.9 | 2 | |
| 6 | 36 | F | 12 | Subfoveal | 48 | 0.05 | 0.2 | 4.4 | 3.2 | 1.6 | 7.68 | 7.5 | 1 | 50 J/cm 2 /83s |
| 7 | 48 | M | 12 | Subfoveal | 46 | 0.15 | 0.1 | 4.69 | 4.17 | 3.0 | 9.29 | 9.1 | 1 | 50 J/cm 2 /83s |
| 8 | 41 | F | 1 | Perifoveal | 46 | 0.1 | 1.0 | 3.05 | 1.9 | 1.3 | 7.29 | 6.8 | 1 | 50 J/cm 2 /83s |
| 9 | 41 | F | 6 | Subfoveal | 44 | 0.02 | 0.03 | 4.3 | 2.9 | 2.5 | 9.4 | 8.0 | 1 | 50 J/cm 2 /83s |
| 10 | 37 | M | 12 | Subfoveal | 36 | 0.08 | 0.08 | 2.7 | 2.2 | 1.7 | 6.5 | 5.3 | 1 | 50 J/cm 2 /83s |
| 11 | 40 | M | 24 | Subfoveal | 36 | 0.04 | 0.02 | 3.9 | 3.9 | 2.2 | 7.8 | 8.8 | 1 | 75 J/cm 2 /125s |
| 12 | 42 | M | 2 | Subfoveal | 36 | 0.01 | 0.01 | 2.9 | 2.4 | 1.9 | 8.4 | 7.6 | 1 | 50 J/cm 2 /83s |
| 13 | 40 | M | 6 | Subfoveal | 32 | 0.2 | 0.2 | 2.8 | 2.2 | 1.5 | 8.1 | 7.9 | 1 | 50 J/cm 2 /83s |
| 14 | 46 | F | 4 | Subfoveal | 32 | 0.1 | 0.7 | 2.3 | 0 | 0 | 6.6 | 0 | 1 | 50 J/cm 2 /83s |
| 15 | 41 | M | 2 | Subfoveal | 31 | 0.01 | 0.01 | 4.4 | 3.0 | 2.8 | 9.2 | 8.3 | 1 | 75 J/cm 2 /125s |
| 16 | 50 | F | 1 | Subfoveal | 30 | 0.1 | 0.05 | 2 | 0 | 0 | 5.9 | 0 | 1 | 50 J/cm 2 /83s |
| 17 | 37 | M | 120 | Subfoveal | 27 | 0.02 | 0.02 | 4.2 | 3.1 | 2 | 8.0 | 6.0 | 1 | 50 J/cm 2 /100s |
| 18 | 35 | M | 1 | Perifoveal | 27 | 0.5 | 1.2 | 2.8 | 2.2 | 0 | 7.9 | 0 | 1 | 75 J/cm 2 /125s |
| 19 | 30 | M | 60 | Subfoveal | 24 | 0.3 | 0.4 | 4.8 | 4.4 | 3.0 | 10.1 | 10.5 | 2 | |
| 20 | 48 | M | 36 | Perifoveal | 24 | 0.05 | 0.25 | 3.2 | 1.5 | 1.2 | 7.2 | 4.6 | 1 | 50 J/cm 2 /83s |
| 21 | 33 | F | 60 | Subfoveal | 21 | 0.15 | 0.15 | 1.6 | 1.5 | 1.1 | 5.8 | 4.2 | 1 | 50 J/cm 2 /83s |
| 22 | 52 | M | 12 | Subfoveal | 18 | 0.01 | 0.01 | 2.3 | 2.3 | 1.8 | 7.9 | 5.1 | 1 | 50 J/cm 2 /83s |
| 23 | 54 | M | 60 | Perifoveal | 15 | 0.05 | 0.5 | 2.6 | 1.3 | 0 | 6.1 | 0 | 1 | 75 J/cm 2 /125s |
| 24 | 45 | M | 60 | Perifoveal | 15 | 0.01 | 0.5 | 2 | 0 | 0 | 9.3 | 0 | 1 | 75 J/cm 2 /125s |
| 25 | 52 | F | 6 | Perifoveal | 12 | 0.02 | 0.2 | 3.7 | 2.2 | 0 | 8.2 | 0 | 1 | 75 J/cm 2 /125s |
a First PDT treatment parameters.
No adverse effects were reported either during or after treatment with PDT. Twenty-three patients received a single session of PDT; in 2 cases, both subfoveal, patients required a second treatment session. Following each treatment with PDT, BCVA measurements, direct ophthalmoscopy, biomicroscopic indirect ophthalmoscopy, B-scan ultrasonography, and fluorescein angiography were performed.
At the end of the follow-up, mean decimal BCVA was 0.31 ± 0.37 (0.01-1.2); this post-treatment increase in BCVA was statistically significant ( P < .01). Eleven of the 25 patients (44%), including 4 subfoveal and all 7 extrafoveal lesions, demonstrated a visual improvement greater than 4 lines (decimal BCVA 0.25-1.2). Among these cases, 3 eyes with extrafoveal lesions showed a visual recovery to decimal BCVA 1.0-1.2 ( Table , Figure 1 ). The BCVA in Case 2, an extrafoveal lesion, increased from 0.04 to 0.4 1 week after treatment, with subsequent improvement to 1.2 a month later. The remaining 14 patients with subfoveal lesions demonstrated resolution of serous retinal detachment, with stabilization of visual acuity.
