PDT for choroidal hemangioma. Case presentation and review of literature

1. Management of choroidal
hemangioma
By
Hany EL-Defrawy, MVR
Fellow
BEH

2. Diffuse choroidal hemangioma
 Rare Sporodic Neuro-Oculocutaneous disorder
 Facial nevus flammeus
 Buphthalmos
 Diffuse choroidal hemangioma (Tomato-Catsup)
 Leptomeningeal hemangiomatosis
 Epilepsy
 MR
 Hemiplegia

7. Circumscribed choroidal hemangioma
 Uncommon, benign vascular tumour
 Discrete, smooth round orange red mass
 Macular and peripapillary region

8. Causes of visual loss
1. Refractive error
2. Foveal distortion
3. Transudative leakage and CMO
4. Serous Retinal detachment with secondary
photoreceptor damage

9. Diagnosis
 Ultrasongraphy
 FFA
 OCT
 MRI

12. When to treat?
 Visual acuity potential
 Extent of detachment

13. Why challenging?
 Limitedtherapeutic options (Why?)
 Surgery (Dangerous)

14.  Size
 Location
 Associated SRF

15. Armamentarium
 External beam radiation therapy (5 observational
studies)
 Proton beam therapy
 Brachytherapy
 Photodynamic therapy
 Cryotherapy
 Transpupillary thermotherapy
 Anti VEGF
 IVTA
 Combined therapy

17. Radiation
 Cataract
 Radiation optic neuropathy
 Retinopathy
 Increase incidence of osteosarcoma
 Chorioretinal atrophy

18. Other modalities
 Plaque Brachytherapy
1. Murthy 2005
2. Zografos 1996
 Proton Beam
 Stereotactic therapy (Gamma Knife)
 Anti VEGF
 PDT

19. PDT
 Anand 2003
 Bains et al 2004
 Singh et al 2005
 Huiskamp 2005
 Tsipursky

21. Ophthalmology 2009;116:100-105

22.  31 patients with CCH and symptoms
 Underwent PDT
 IV Verteporfin 6 mg/m 2
 689nm laser
 15 min laser 50j/cm 2 83 sec exposure
 1-4 treatment
 Follow up 12 month

23.  Primary end point
1. Absence of exudative RD at 12 month
follow up (FFA,OCT, Ophthalmoscopy)
 Secondary endpoint
1. Visual acuity
2. Tumour thickness decrease
3. Adverse events

24.  Inclusion criteria
1. 18 with CCH height 5 mm and diameter 12 mm
2. Exudative RD affecting the fovea
3. No cataract within last 2 months
 Exclusion criteria
1. NYHA Class III-IV
2. Porphyria
3. Liver disease
4. Active hepatitis

25. Results
 82.8% 1 session
 13.8% 2 sessions
 3.4% 3 sessions
 Visual acuity increased mean 20/60 to 20/ 35
 CMO regressed and Exudative RD disappeared in all
except 2 cases.
 CCH thickness decreased from 3 to 1.7 mm
 Visual fields showed resolution of central scotomas
 No adverse events

28. Am J ophthalmol 2010

29.  Retrospective
study of 14 patients with
symptommatic circumscribed choroidal
hemangioma who underwent PDT± IVTA
 Shao Huang, James Fabian etal. Optometery and
visual science , 2009.

30.  Symptomatic visual loss
 Exudative Detachment
 Macular edema
 Subfoveal fluid
 Tumour encroaching to within 2 mm of the
fovea.

31.  7.5 mm spot size
 Overlapping spots
 83 sec
 IVTA (0.1ml of 40 mg/ml)
 Baseline VA
 IOP
 Macular thickness
 10 eyes PDT
 4 PDT and IVTA

32. Conclusion
 Optimal treatment settings remains a matter
of debate for CCH
 Variable number of spots
 Ranging Spot size (2500-7700µ)
 Ranging duration (60-83sec)
 Overlapping vs non overlapping spots
 Number of treatment sessions