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Introduction: Choroidal osteoma (CO) is a rare benign ocular tumor characterized by ossifying choroid lesions. To the best of our knowledge, this is the first detailed report to describe the optical coherence tomography angiography (OCTA) findings of choroidal neovascularization (CNV) complicated by a rare decalcified CO following intravitreal aflibercept injection. Patient concerns: A 26-year-old woman presented with a spontaneous but painless reduction in visual acuity in her left eye that had commenced 5 days prior. Diagnosis: Clinical manifestations and multimodal imaging, including OCTA, spectral-domain optical coherence tomography, fundus fluorescein angiography and indocyanine green angiography, indicated decalcified CO with CNV. Interventions: After receiving an appropriately detailed explanation of the procedure, the patient was treated via intravitreal aflibercept(2.0 mg) injection once. Outcomes: One month after the therapy, OCTA revealed that the flow areas of CNV were narrowed, the best-corrected visual acuity was improved to 20/30, however, 2 months follow-up OCTA revealed that the CNV reoccurred, the best-corrected visual acuity was dropped to 20/50. Conclusion: Intravitreal aflibercept injection was an effective treatment for CO with CNV, but the effects may not last long. The OCTA findings provide a better appreciation of evaluating the effects of intravitreal aflibercept injection for CO complicating CNV.

PURPOSE To report a case of bilateral choroidal osteoma, which demonstrated different visual outcomes in both eyes over a long follow-up of 45 years. METHODS Case report. RESULTS After 45 years of follow-up, choroidal osteoma showed slight enlargement in each eye and choroidal neovascularization and retinal pigment epithelium (RPE) changes had developed in the right eye. Visual acuity of the right eye was decreased to 20/200 from macular RPE loss and choroidal neovascularization scarring. The left eye preserved a visual acuity of 20/30 where choroidal osteoma demonstrated only partial decalcification of the nasal margin with preservation of RPE in the macular region. Spectral domain optical coherence tomography of the right macula confirmed broad RPE and choroidal atrophy and scarring related to previous choroidal neovascularization. Spectral domain optical coherence tomography of the left macula showed preserved retinal layers and RPE with underlying calcified choroidal osteoma. CONCLUSION Choroidal osteoma can occasionally demonstrate intact calcification, preserved RPE, and photoreceptors with excellent vision.

Dear Editor, We appreciate the opportunity to further discuss our recent report on the “Pitchfork Sign”, a distinctive optical coherence tomography (OCT) finding in inflammatory choroidal neovascularization (CNV), Retina 2013; 33:1049–1055.1 in particular, to respond to the interest and letter from Vagge et al., who noted similar hyperreflective finger-like projections from type 2 neovascularization in the setting of vitelliform macular dystrophy (VMD). Of interest, the case in their report, as well as a prior case reported by de Mello et al. in the setting of CNV associated with choroidal osteoma,2 the “pitchfork” occurred in areas of subretinal hemorrhage. In the current case described by Vagge et al., it appears that thick subretinal hemorrhage and possibly fibrin may be distorting the outer retina, producing the OCT findings. In the four cases in our original series,1 there was little to no hemorrhage present. The main purpose of our original manuscript1 was to describe an OCT finding that would be helpful in distinguishing cases of multifocal choroiditis / punctate inflammatory choroidopathy (MFC/PIC)-related CNV from idiopathic or myopic CNV where the diagnosis was uncertain. In Vagge et al.’s report, and de Mello et al.’s case,2 there are known predisposing risk factors for CNV; therefore, although the presence of this OCT finding is interesting, it is of less clinical relevance when the diagnosis is clear.

The purpose of this study was to evaluate the effect of intravitreal injection of bevacizumab on subretinal fluid associated with choroidal osteoma.In this retrospective noncomparative case series, eyes with serous retinal detachment involving the macula were treated with intravitreal injection of bevacizumab (1.25 mg/0.05 mL) and carefully followed-up with complete ophthalmic examination, including angiography and optical coherence tomography. The changes in best-corrected visual acuity and central foveal thickness were assessed by optical coherence tomography.Six eyes received intravitreal injection of bevacizumab for serous retinal detachment. Only one eye had choroidal neovascularization associated with serous retinal detachment. The mean number of injections for the 6 eyes was 2.0 during the mean follow-up period of 11.3 months. The median logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.70 (Snellen equivalent, 20/100) at baseline to 0.30 (Snellen equivalent, 20/40; P = 0.043) at the final visit. The optical coherence tomography result also showed a significant reduction in central foveal thickness with a median central foveal thickness of 357.0 microm at baseline and 169.50 microm at the final visit (P = 0.028). The treatment was well tolerated, without ocular or systemic adverse events.Intravitreal injection of bevacizumab for serous retinal detachment secondary to choroidal osteoma resulted in both visual and anatomical improvements.

PURPOSE To report the effect of off-label use of bevacizumab (Avastin) in the treatment of choroidal neovascularization associated with a choroidal osteoma. METHODS Interventional case report examining antivascular endothelial growth factor therapy used for choroidal neovascularization complicating a choroidal osteoma. RESULTS A 24-year-old man with a choroidal osteoma presented with metamorphopsia and decreased vision in his left eye of 20/60. Clinical examination, fluorescein angiography, B-scan ultrasonography, and optical coherence tomography revealed a well-circumscribed macular choroidal osteoma with overlying subretinal hemorrhage and a choroidal neovascular membrane. The patient was treated with a series of 3 intravitreal bevacizumab (Avastin) injections (1.25 mg/0.05 mL) performed at baseline, 1 month, and 2 months. Treatment resulted in resolution of subretinal hemorrhage and fluid with improvement in visual acuity to 20/30 at the 5-month follow-up. CONCLUSION Intravitreal bevacizumab seems to be a promising treatment for choroidal neovascularization (CNV) associated with choroidal osteomas.

PURPOSE To report a case of serous retinal detachment (SRD) associated with choroidal osteoma successfully treated with transpupillary thermotherapy (TTT). METHODS A 21-year-old woman presented with a 1-month history of blurred vision in the right eye. RESULTS Visual acuity was 20/50 in the right eye and 20/20 in the left eye. Fundus examination of the right eye revealed a suprapapillary choroidal osteoma associated with SRD extending to the macula. Fluorescein angiography showed diffuse mottled hyperfluorescence of the tumor associated with a moderately leaking area at its inferior border within the area of SRD. There were neither obvious features of choroidal neovascularization nor typical focal retinal pigment epithelial leaks. TTT, applied to the leaking area in one session using an 810-nm diode laser, resulted in resolution of subretinal fluid and subsequent improvement in visual acuity to 20/25. CONCLUSION TTT can be considered as treatment for patients with choroidal osteoma complicated by SRD.

Treatment of subretinal neovascular membranes associated with choroidal osteomas is described. Early recognition of the membranes, aided by Amsler grid self-assessment, allowed initiation of photocoagulation treatment while the lesions were still extrafoveal. In one patient, initial treatment was performed with the argon green laser and subsequent treatments were applied with the krypton red laser. In two other patients, argon-laser photocoagulation alone was used to destroy subretinal neovascular membranes. Post-treatment evaluations in one patient demonstrated persistence of recurrence of neovascular tissue and allowed for prompt retreatment. Follow-up evaluations have shown that treatment resulted in persistent destruction of the subretinal neovascular membrane in two patients, with stabilization of vision at 20/25- and 20/100, respectively. In one patient, vision has been stable at 20/50 for 6 months; however, a recurrent subretinal neovascular membrane developed, encroaching through the fovea with resultant visual loss of 20/60.