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Choroidal freckle. A, Color fundus photography showing choroidal freckle in the temporal superior arcade. B, OCTA of the retinal superficial layer showing a normal retinal circulation. C, OCTA of choriocapillaris layer showing a hyperreflective well-demarcated plexus on the nevus showing a normal pattern. D, Choriocapillaris en face OCT shows an adequate intensity signal and hyperreflectivity of the lesion. E, EDI-OCT shows position of the lesion in choroidal layer. EDI ¼ enhanced-depth imaging; OCTA ¼ OCT angiography.
Source publication
Objective: Optical coherence tomography angiography (OCTA) is a new, noninvasive imaging modality used to assess the vasculature in chorioretinal disease. The purpose of this study was to describe OCTA findings in several chorioretinal tumors, specifically melanocytic tumors. We correlate these findings with clinical risk factors (RFs) for growth....
Contexts in source publication
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... evaluated 79 patients (43 females and 36 males) with a mean age of 63.76 years. There were 42 right eyes and 37 left eyes; Figure 13. Low-grade choroidal lymphoma. ...
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... within the lesion were described as "fine" in 2 cases (4.5%), "normal" in 32 cases (72.7%), and "thick" in 10 cases (22.7%). In some cases, the plexus over the nevus showed large hyporeflective areas consistent with overlaying fibrosis or drusen, causing a blockage of the signal (Tables 2 and 3; Fig 1; Fig S2, available at www.ophthalmologyretina.org). ...
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... Capillary Hemangioma. We found that OCTA can detect vascular flow within the hemangioma and depict feeding Figure 14. Choroidal osteoma (osteoblastic phase). ...
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... as a fine, dense meshwork in the tumor. This could be useful in the diagnosis and follow-up after ablative treatments in these patients (Fig 10). ...
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... our study, images showed a very disorganized choroidal plexus with anastomosis, thick and fine vessels, large avascular zones, and vascular loops. The accessi- bility, speed, and noninvasive nature of OCTA could be beneficial in cases when diagnosis proves difficult (Fig 11). ...
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... Lymphoma. In our first case (mucosa-associated lymphoid tissue [MALT] lymphoma) OCTA showed a hypore- flective, heterogenic plexus in the areas of choroidal infiltration with large atrophic areas between them (Fig 12). ...
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... our second case (low-grade B-cell uveal lymphoma) OCTA nicely showed a thick hyperreflective/isoreflective, heterogenic plexus beneath the RPE (Fig 13). ...
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... used OCTA to study a choroidal osteoma in the osteoblastic phase. Images showed a hyporeflective, fine, homogeneous, granular plexus with defined edges over the lesion (Fig 14). ...
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... our study, OCTA of congenital hypertrophy of retinal pigment epithelium (CHRPE) showed a disorganized plexus over the lesion in all retinal layers; vascular tortuosity was also noticeable. The sur- rounding retinal plexus and choroidal plexus appeared normal (Fig 15). ...
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... 2 of our cases, OCTA showed a dense, congestive, organized, and well-defined network corre- sponding to the circulation of the hamartoma. The retinal superfi- cial plexus, deep retinal layer, and choroidal layer appeared normal, whereas the third case showed miss-segmentation and artifacts related to tissue irregularity and calcification (Fig 16). ...
Citations
... Cennamo et al. [16] evaluated OCTA images from 116 choroidal tumours, finding that flat choroidal nevi had a normal choriocapillaris layer, while melanomas had a dense, irregular vascular network. Toledo et al. [18] found that the presence of a hyporeflective plexus and hyperreflective ring correlated with higher risk lesions. Ghassemi et al. [17] found that choriocapillaris vascular flow was lower in melanomas than in choroidal nevi. ...
Simple Summary
The differential diagnosis between small melanocytic lesions and choroidal nevus is challenging. We usually rely on clinical risk factors to establish the need for immediate treatment vs. close monitoring followed by treatment if the lesion grows. We aimed to describe the features of small indeterminate choroidal melanocytic lesions visualized on optical coherence tomography angiography (OCTA) and to identify the predictors of growth. Our findings show that the vessel diameter quantified by OCTA can help differentiate between choroidal nevi and small melanomas, when considered together with clinical risk factors.
Abstract
In this study, we aimed to identify the features of indeterminate choroidal melanocytic lesions visualized on optical coherence tomography angiography (OCTA) and to identify the predictors of growth. We retrospectively evaluated 86 patients with indeterminate lesions treated at our centre from 2016 to 2021. Clinical management involved active surveillance followed by brachytherapy if growth was detected. The lesions were classified into two groups according to whether they grew (small melanomas) or remained stable (choroidal nevi). Growth was detected in 19 (22.1%) lesions. All patients underwent OCTA at baseline. These images were compared to identify the possible predictors of growth. Significant between-group differences were observed in thickness (p = 0.00), greatest basal diameter (p = 0.00), number of risk factors (p = 0.00), symptoms (p = 0.001; relative risk [RR]: 4.3), orange pigment (p = 0.00; RR: 6.02), and ultrasonographic hollowness (Kappa sign); p = 0.000; RR: 5.3). The melanomas had significantly more vessels with a diameter ≥ 76.3 µm (p = 0.02; RR: 2.46). The time to growth in these lesions was significantly shorter (p = 0.05) than in lesions with smaller vessels. These findings show that vessel diameter quantified by OCTA can help differentiate between choroidal nevi and small melanomas, when considered together with clinical risk factors.
... There have been few reports in the literature investigating SS-OCT and SS-OCTA findings in a limited number of CCH cases [4,6,7,[14][15][16][17]. Herein, we report the SS-OCT/ SS-OCTA findings in 21 CCH cases. ...
... In our study, B-scan angiography overlay demonstrated increased flow signals over the tumor in all eyes. Similarly, Toledo et al. reported high vascular flux over CCHs in B-scan overlay [15]. Quiescent tumors with few intratumoral vessels were reported to remain stable [22]. ...
Purpose
To investigate the swept-source optical coherence tomography (SS-OCT) and SS-OCT angiography (SS-OCTA) findings in circumscribed choroidal hemangioma (CCH) before and after treatment with transpupillary thermotherapy (TTT).
Methods
The clinical records of 21 eyes having CCH imaged with SS-OCT/SS-OCTA between September 2018 and December 2022 were evaluated.
Results
SS-OCT examination in CCH showed dome-shaped appearance (100%), choroidal shadowing (100%), expansion of choroidal structures (100%), subretinal fluid (66.7%), intraretinal edema/schisis (33.3%), retinal pigment epithelium (RPE) atrophy (19.0%), hyperreflective dots (19.0%), and epiretinal membrane (4.8%). Internal arborizing tumor vessels showing hyperreflectivity were observed in the choriocapillaris slab on SS-OCTA in all eyes. In the deep capillary plexus (DCP), flow void changes were seen in 7 eyes with intraretinal schisis/cystoid macular edema. Four CCHs > 2 mm in thickness showed outer retinal involvement due to unmasking of flow in intratumoral vessels related to RPE atrophy. Following TTT/indocyanine green-enhanced TTT (ICG-TTT) of CCH, SS-OCT findings included total/partial resolution of subretinal fluid (57.1%), complete/partial regression of the tumor (52.4%), and RPE atrophy (33.3%). After treatment; loss of choriocapillaris, decrease in tumor vascularity together with increase in the fibrous component and flow void areas were detected on SS-OCTA.
Conclusions
SS-OCT/SS-OCTA are useful non-invasive tools for imaging the structural/vascular changes in CCHs managed with TTT or ICG-TTT. On SS-OCTA, hyporeflective spaces localizing to edema/schisis in the DCP and arborizing tumor vessels within a hyporeflective stromal background in the choriocapillaris slab were observed. After TTT/ICG-TTT, a decrease in tumor vessels and an increase in the fibrous component and flow-void areas inside the CCH were detected on SS-OCTA.
... Although several previous studies have used OCTA to identify vascular patterns in choroidal melanocytic lesions [13][14][15][16][17][18][19], the use of this imaging technique remains relatively limited. Moreover, only a few studies have used OCTA to compare choroidal nevi and choroidal melanomas [20][21][22][23]. ...
... Cennamo et al. [16] evaluate OCTA images from 116 choroidal tumours, finding that flat choroidal nevi had a normal choriocapillaris layer while melanomas had a dense, irregular vascular network. Toledo et al. [18] found that the presence of a hyporeflective plexus and hyperreflective ring correlated with higher risk lesions. Ghassemi et al. [17] found that choriocapillaris vascular flow was lower in melanomas than in choroidal nevi. ...
In this study, we aimed to identify the features of indeterminate choroidal melanocytic lesions visualized on optical coherence tomography angiography (OCTA) and to identify predictors of growth. We retrospectively evaluated 86 patients with indeterminate lesions treated at our cen-tre from 2016 to 2021. Clinical management involved active surveillance followed by brachy-therapy if growth was detected. The lesions were classified into two groups according to wheth-er they grew (small melanomas) or remained stable (choroidal nevi). Growth was detected in 19 (22.1%) lesions. All patients underwent OCTA at baseline. These images were compared to iden-tify possible predictors of growth. Significant between-group differences were observed in thickness (p=0.00), greatest basal diameter (p=0.00), number of risk factors (p=0.00), symptoms (p=0.001; relative risk [RR]: 4.3), orange pigment (p=0.00; RR: 6.02), and ultrasonographic hol-lowness (Kappa sign); p=0.000; RR: 5.3). The melanomas had significantly more vessels with a diameter ≥ 76.3 µm (p=0.02; RR: 2.46). The time to growth in these lesions was significantly shorter (p=0.05) than in lesions with smaller vessels. These findings show that vessel diameter quantified by OCTA can differentiate between choroidal nevi and small melanomas, especially when considered together with clinical risk factors.
... Patients typically present with nonspecific complaints of painless blurred vision, floaters or both. Examination of the posterior segment reveals vitritis and development of creamy lymphoma choroidal infiltration with orange-yellow infiltrates deep to the RPE (4,8). These creamy lesions can also develop in the posterior pole of retina. ...
Primary vitreoretinal lymphoma (PVRL) is often associated with central nervous system involvement, contributing to a heightened mortality rate, thus imaging features that are characteristic enough to be potential biomarkers of PVRL are important, either in diagnosis or in assessment of disease activity. This report details the case of a 68-year-old male who presented with blurred vision in both eyes persisting for 2 months. Fundus examination demonstrated vitreous opacity and multiple subretinal yellow nodular lesions of varying sizes in the peripheral fundus of both eyes. Multiple vertical hyperreflective lesions in the neural retina of posterior pole, indistinct outer retina borders in the fovea, and hyperreflective lesions in the sub-retinal pigment epithelium (RPE) space of the peripheral retina were demonstrated on swept-source optical coherence tomography (SS-OCT) of the left eye. Hyperflow signals corresponding to the vertical hyperreflective lesions were detected on swept-source optical coherence tomography angiography (SS-OCTA) images of retinal deep capillary plexus (DCP) layer. Notably, the hyperflow signals, precisely located around retinal vessels from the nerve fiber layer to the outer plexiform layer, were postulated to stem from the dilation of infiltrated retinal vessels. Vitreous pathological results of the left eye confirmed the diagnosis of PVRL. Treatments with intravitreal methotrexate injections led to a marked improvement of best-corrected visual acuity (BCVA) and regression of the hyperflow microinfiltration lesions demonstrated on SS-OCTA. In conclusion, SS-OCTA effectively delineated the vertical hyperreflective lesions and corresponding hyperflow signals in the posterior pole macular region of a patient with PVRL. These lesions significantly diminished following intravitreal methotrexate injections. We speculated that the specific hyperflow signals on SS-OCTA could act as a potential biomarker of PVRL, and SS-OCTA holds promise in facilitating early diagnosis and monitoring therapeutic responses in PVRL cases.
... The choroidal nevi are mainly seen as heterogenic and hyperreflective lesions. When studying melanocytic tumors, the higher risk of malignancy (choroidal melanoma) is associated with the presence of parilesional hyporeflective plexus or hyperreflective ring (in the choriocapillaris layer) [22] (Figure 13). ...
OCT becomes an indispensable tool in everyday practice. OCTA is the functional extension that provides cross-sectional information on retinal and choroidal circulations without dye injection. It allows visualization of abnormal flow in areas with no flow and abnormal vessels (like CNVM). In ARMD, it can detect active membranes before being leaky in FFA. In diabetic retinopathy, OCTA can diagnose abnormal areas of non-perfusion in the superficial plexus, deeper capillary structures, or neovascularization. OCTA can detect focal dilation and foveal capillaries alterations in macular telangiectasia. It is useful in the diagnosis of inherited retinal diseases such as retinitis pigmentosa. OCTA has many challenges including longer acquisition times and motion artifacts. Longer wavelength SS-OCT may provide a solution for imaging through media opacities and a wider field of view. OCTA does not give full details about the retinal periphery, also, it gives no information about blood-retinal barrier (no dye to leak); an important sign in many retinal diseases.
... In accordance with previous studies we found no significant changes of choriocapillaris perfusion and this fact agrees with the suggestion that the link between choroidal nevi and CSCR is indirect. [29][30][31] This study has several limitations. Firstly, we used a specific imaging modality, DF-SLO. ...
Background
A number of articles report the association of polypoidal lesions and choroidal nevi; however, the relationship between choroidal nevi and pachychoroidal disorders has not been studied.
Objectives
To study the prevalence of choroidal nevi in central serous chorioretinopathy (CSCR) patients and to elucidate potential differences in the clinical characteristics of CSCR in patients with and without choroidal nevi.
Design
Case-control study.
Methods
This study included a retrospective analysis of medical records and multimodal imaging data of CSCR patients and a prospective evaluation of the prevalence of the choroidal nevi in age- and sex-matched healthy controls. All participants received comprehensive ophthalmic examination and multimodal imaging including infrared scanning laser ophthalmoscopy in dark-field mode to detect choroidal nevi in the central 40° × 60° region.
Results
A total of 199 CSCR patients (160 males and 39 females, 47.9 ± 9.4 years) and 184 age-matched healthy individuals (139 males and 45 females, 44.8 ± 12.5 years) were included. Choroidal nevi were detected in 24 (12.1%) CSCR patients and 10 (5.4%) healthy controls ( p = 0.01). CSCR patients with choroidal nevi had statistically significantly higher subfoveal choroidal thickness, lower best-corrected visual acuity, and lower central retinal thickness ( p < 0.05) than CSCR patients without choroidal nevi. The odds ratio for the presence of chronic CSCR in patients with choroidal nevi was 27.0 (95% CI: 3.1–231.9, p = 0.003).
Conclusion
The prevalence of choroidal nevi among patients with CSCR is higher than in age- and sex-matched healthy population. Choroidal nevi may be associated with chronic CSCR.
... OCT angiography (OCTA) reveals a well-defined, hyperreflective lesion and finely branching tumor vessels. 16,17 Retinal flow signals within the tumor can be detected on B-mode angiography (Figure 1e). The tumor vasculature is seen in the superficial and deep retina (Figure 1f,g). ...
Hamartomas are local malformation of cells that demonstrate abnormal proliferation in the area where they are normally present. Retinal and optic disc hamartomas include astrocytic hamartoma, congenital hypertrophy of the retinal pigment epithelium (CHRPE), simple congenital hamartoma of the retinal pigment epithelium (CSHRPE), combined hamartoma of the retina and retinal pigment epithelium (CHRRPE), retinal hemangioblastoma (retinal capillary hemangioma), and retinal cavernous hemangioma. Retinal and optic disc hamartomas can be observed sporadically as well as with systemic associations. Astrocytic hamartoma usually appears as a flat, transparent yellowish lesion. CHRPE is a round, pigmented, and flat lesion. CSHRPE usually presents as a dark black macular tumor. CHRRPE consists of vascular, glial, and pigment epithelial components, which can demonstrate peripapillary, macular, and peripheral localization. Retinal hemangioblastoma is a vascular tumor, red-pink in color with tortuous and dilated afferent and efferent vessels, typically located in the peripheral retina or optic disc. Retinal cavernous hemangioma is characterized by the formation of thin-walled saccular angiomatous structures in the retina or optic nerve head resembling concord grapes. Ultrasonography, fundus autofluorescence, optical coherence tomography, optical coherence tomography angiography, and fluorescein angiography methods are used in the diagnosis of retinal and optic disc hamartomas. Some retinal and optic disc hamartomas do not require treatment. However, complications including vitreous hemorrhage, macular exudation, retinal detachment, macular hole, epiretinal membrane, and choroidal neovascularization require treatment.
... OCT is not an appropriate diagnostic instrument in the case of peripheral and very large tumors, as the periphery of the retina and choroid is barely accessible with this imaging modality [59]. However, this problem may be solved soon, as SS-OCT technology with 20-and 40-diopter indirect ophthalmoscopy lenses can provide wide field-of-view images of the peripheral tumors [60]. A wide field-of-view image corresponds to a scanning area equal to 4.6 times the distance between the optic disk and fovea; meanwhile, the mean scanning area accessible with SD-OCT is only 2.1 times the distance between the two structures mentioned above. ...
Choroidal melanoma requires reliable and precise clinical examination and diagnosis to differentiate it from benign choroidal nevi. To achieve accurate diagnosis, as well as monitoring the progression of disease, various imaging modalities are used, including non-invasive optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA). This review begins with a historical account of the development of OCT and OCTA and the methods of generation of images. This outlines the understanding of what OCT/OCTA images show, as well as how image artifacts arise. The anatomy and imaging of specific vascular layers of the eye are introduced. Then, anatomical aspects of choroidal melanoma, its diagnosis and differentiation from metastasis, and choroidal nevi are presented. The purpose of this review is to critically evaluate application of OCT and OCTA in the diagnosis of choroidal melanoma.
... Detecting CNV in eyes with osteoma using traditional imaging (e.g., FA and ICGA) can be challenging because of high tissue density within the tumor, and secondary RPE abnormalities that promote irregular and persistent hyperfluorescence; consequently, it is difficult to distinguish CNV from feeder vessels [21,26]. OCTA is superior to FA and ICGA in terms of visualizing CNV, including the contour and shape of vessels [27]. Since first reported by Szelog in 2016 [5], several studies have described CNV in patients with CO, as detected by OCTA from a relatively small number of cases [8][9][10]22,28,29]. ...
Choroidal neovascularization (CNV) secondary to choroidal osteoma (CO) can cause profound visual loss, but detecting CNV and the tumor’s feeder vessels using traditional fluorescent angiography imaging is challenging. Newly developed TowardPi swept-source optical coherence tomography (SS-OCT) and OCT angiography (SS-OCTA) enable ultra-high resolution, enhanced penetration with longer wavelength (1060 nm), a rapid scan rate (400 KHz), reduced loss of signal strength with increasing depth, and 120° angular widefield of fundus view, enabling a nearly histological description of the retina and choroid. We therefore used this SS-OCT and SS-OCTA platform to observe the intrinsic features of osteoma in 23 eyes of 21 patients. It was found that the borders of CO were clearly demarcated from the adjacent choroidal Sattler’s and Haller’s layers, while on a corresponding B-scan the blood flow of the CO was detected mainly within the choriocapillaries and partly within Sattler’s layer. The CNV was identified as numerous branching or radiating vessels connecting with intrinsic feeder vessels displaying various patterns including ginseng, instant noodle, growth ring, tangle, spider web, medusa, seafan, and irregular shape. Moreover, tumor-like tissues were found to grow above the disrupted Bruch’s membrane. SS-OCTA can be used to detect the tumor vasculature in CO.
... [9,10] Other studies focused on the appearance of choriocapillaris: main findings were a decreased flow rate in choroidal melanomas compared to choroidal nevi with nevi also presenting an intense vascular rim. [11][12][13] According to Garcia-Arumi Fuste et al. choroidal nevi are hyperreflective with few avascular areas but distinct margins compared to melanomas, which display ill-defined margins, multiple intrinsic avascular areas and flow voids at the level of the choriocapillaris (Fig. 1). [14] The introduction of SS-OCTA has later improved the imaging of ocular tumors, offering enhanced penetration into deep tissues and better visualization of the choroid. ...
... Most of the reports describe the presence of mixed areas of hypo and hyperreflectivity within the choroid, with variable amount of intrinsic flow voids. [11] The apparent lack of intrinsic blood flow at OCTA has been correlated to either a shadowing artifact from the overlying intra/subretinal fluid or to the high blood flow velocity characterizing the tumor's vessels (fringe effect). [18] Within the lesions, disorganized intratumoral vasculature showing both thick and fine vessels, anastomoses and vascular loops have also been reported on SS-OCTA ( Fig. 3 A-E). ...
... [18] Within the lesions, disorganized intratumoral vasculature showing both thick and fine vessels, anastomoses and vascular loops have also been reported on SS-OCTA ( Fig. 3 A-E). [11] Circumscribed Choroidal Hemangioma Secondary to their typical posterior location, their amelanotic appearance and the notable role of dye-based imaging techniques for confirming their diagnosis (ICGA, in particular, shows a pathognomonic early filling and late wash-out of in correspondence of the tumor), circumscribed choroidal hemangiomas (CCHs) have been the focus of several studies since the very first introduction of SD-OCTA devices into clinical practice. According to the literature, on OCTA CCHs are characterized by large, dense, intertwined vascular trunks originating from a circular vascular arcade surrounding the lesion and well-defined margins (Fig. 3 H). ...
Background: Optical Coherence Tomography Angiography (OCTA) is a valuable imaging tool for the diagnosis of several retinal and choroidal diseases. Its role in ocular oncology is clinically promising but still controversial. In this review we report the main applications and limits of the use of OCTA for the study of intraocular tumors. Summary: OCTA allows a rapid, safe, low-cost and high-resolution visualization of the retinal and choroidal vasculature. Attempts have been made to use this technology in ocular oncology to differentiate benign and malignant lesions and to assist physicians in the evaluation and monitoring of post-treatment complications. Main limitations include failure in correct segmentation due to tumor inner profile or thickness, poor penetration of laser into the lesion, masking effect from overlying fluid and media opacities and poor fixation. Key messages: The main applications of OCTA in ocular oncology consist in the documentation of tumor-associated choroidal neovascularizations and the study of vascular changes following tumor treatments. In particular, the diffusion of wide-field protocols makes OCTA suitable for the diagnosis and follow-up of radiation chorio-retinopathy allowing a detailed visualoization of both macular and peripheral ischemic changes. Optimistically, future innovations in OCTA technology may offer new perspectives in the diagnosis and follow-up of intraocular tumors.
