CASE OF THE MONTH: December 2021
Superior scotoma and flashes in a young myope
- 37 year-old female presents with history of six weeks of a “spot” in her superotemporal visual field with flashes in the right eye
- At presentation, she has been asymptomatic for one week
- Past medical history: Hashimoto’s disease, shingles (fall 2020)
- Past ocular history: myopic LASIK (2010)
- Social history: Never smoker
- Family history: None
- Visual acuity: 20/20-1 OU
- IOP: 15, 14
- Pupils: No RAPD
- Anterior segment: Unremarkable OU
- White retinal lesion
- Retinal necrosis
- History of Zoster in 2020
- No current lesions
- No other systemic symptoms
- Primary vitreoretinal lymphoma
- Denies fevers, chills, weight loss
- Infectious/inflammatory lesions
- No risk factors, no relevant travel history
- Denies systemic symptoms
- Sarcoid granuloma
- Denies related systemic symptoms
- Retinal capillary hemangioma
- Von Hippel-Lindau
- No family history
- No systemic associations
- Absence of markedly dilated and tortuous feeder vessels
- Lacks characteristic angiographic appearance of marked hyperfluroescence of entire tumor
- Von Hippel-Lindau
- Amelanotic melanoma
- B-scan low and decreasing internal reflectivity with choroidal shadowing
- Peripheral exudative hemorrhagic chorioretinopathy
- Associated with large subretinal hemorrhage and exudate
- Lack telangiectatic feeder vessels
- Older patients
Retinal Vasoproliferative Tumor (VPT) with (receding) associated exudative retinal detachment
- Uncommon, benign, yellow-pink, dome-shaped retinal tumors with an overlying network of fine, telangiectatic vessels
- Primarily located inferotemporally or inferiorly in the retina
- May be isolated (primary) or associated with underlying ocular condition (secondary)
- Associated exudation, macular edema, retinal detachments, and epiretinal membranes can result in decreased vision
- Appropriate for small, peripheral tumors that do not compromise vision
- Laser photocoagulation
- Useful for small tumors, usually as complement to other modalities
- Trans-scleral cryotherapy
- May induce tumor regression
- Adverse effects include macular edema, retinal detachment
- Photodynamic therapy/Transpupillary thermotherapy
- Useful in inducing regression for tumors of moderate thickness
- Indicated for large lesions and those associated with retinal detachment
- Adverse effects include dry eye, cataract, optic neuropathy/retinopathy, neovascular glaucoma
- Surgical resection
- Indicated when tumors fail to respond to cryotherapy or in cases with persistent vitreous hemorrhage
- Intravitreal anti-VEGF
- Associated with temporary reduction in tumor thickness but have limited efficacy as long-term monotherapy
Back to our case:
- Patient offered: observation, cryotherapy, trans-pupillary thermotherapy
- Plan: Observation, avoid blood thinners and vigorous activity
- Five months later: Heme resolved, lesion inactive without recurrent exudation (and resolved SRF), observed
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