First Author: P.Y.Sin HONG KONG
Co Author(s): E. Lo A. Young 0 0 0 0 0 0 0 0 0
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To illustrate the workup and course of treatment of polypoidal choroidal vasculopathy presenting as a large choroidal mass
A 62 year-old lady, who had breast cancer treated since 2009, complained of drop in visual acuity and metamorphosia over her right eye for 1 month. She was referred as possible choroidal metastasis from a private ophthalmologist to the Ophthalmology Department in Prince of Wales Hospital in Hong Kong.
History revealed that she received right mastectomy and adjuvant chemotherapy in 2009 for treating her breast cancer and was now on aromatase inhibitor. She had no recent weight loss, cough or bone pain. At presentation, her right eye’s visual acuity was 20/40 and left eye’s was 20/20. Fundus examination of her right eye showed an oval-shaped subretinal mass located at the inferior vascular arcade near and encroaching onto macula, with size measuring around 5-disc diameter. The mass was reddish orange in color, with no overlying subretinal fluid nor orange pigments. There was subretinal hemorrhage inferior to it but with no exudation. Fundus examination of her left eye was normal. B-scan ultrasonography of the right eye depicted a hyper-echoic mass with high internal reflectivity on the A-scan. There was no choroidal excavation. Optical coherence tomography showed an abruptly elevated mass in the right eye with no visibility of the underlying RPE or choroid due to optical shadowing. No subretinal fluid overlying the mass was found but was detected in line scans near the fovea.
Fundus fluorescein angiography (FA) revealed faint hyperfluorescent of the mass with adjacent hypofluorescent corresponding to area of subretinal hemorrhage. Indocyanine green (ICG) angiography revealed early hyperfluorescent in dilated choroidal vessels in the fovea and several points within the mass, which increased in size and intensity over time. The features however were atypical for polypoidal choroidal changes nor suggestive of ocular metastasis. MRI brain and orbit showed the mass, measuring 1.6mm in thickness and 6.7mm x 15.7mm in diameter, was isointense in T1 and hypointense in T2. The patient was referred for oncological assessments that did not suggest any disease recurrence and metastasis. PET-CT body scan showed no significant increase in FDG uptake. Diagnosis of polypoidal choroidal vasculopathy (PCV) was presumed despite that the features were atypical. A trial of photodynamic therapy (PDT) with anti-VEGF injection to her right eye was given which improved her symptoms of metamorphosia and visual acuity to 20/30 after 2 months’ time. The choroidal mass however did not change in size. Two monthly intravitreal anti-VEGF injections were further administered. After 5 months, the choroidal mass resolved gradually with atrophic scarring in the overlying retinal pigment epithelium.
PCV can masquerade as a choroidal tumor. Choroidal mass can be benign or malignant neoplasm but could also be other conditions such as PCV, inflammatory granuloma, hemorrhagic pigment epithelial detachment, etc. In the context of past history of breast cancer in this patient, to rule out the possibility of choroidal metastases is particularly important because it affects the management and prognosis. Frequently, choroidal mass presents with no salient features or distinguishing characteristics in indirect ophthalmoscopy and ultrasound examinations. Despite the availability of diagnostic tools like OCT, FA and ICG, MRI and PET-CT scan, nonspecific features are often the case which render the diagnosis challenging.