1. Retina Imaging Conference
Brett Mueller, D.O., Ph.D.
2/11/2016
University of Louisville
Department of Ophthalmology and Visual Sciences

2. Patient Presentation CC: Decreased Vision Left Eye
HPI: 59 yo WM presents w/ gradual, painless blurry vision OS that has been getting worse for the past several months. Pt denies any history of trauma, HAs, or jaw claudication.

3. History
POHx: none
PMHx: Hypertension and controlled on medical management
FAMHx: none
ROS: none
MEDS: Metoprolol, aspirin, and a statin
ALLERGIES: none

4. Exam VA TP P 18 20 3→2 EOM: full OU 20/20 (+1.25 sph)
20/CF 1 ft (+1.75 sph) 18 20
3→2
NO RAPD
EOM: full OU

5. Exam OD OS LIDS/LASHES WNL WNL CONJ WNL WNL CORNEA WNL WNL
IRIS WNL WNL
LENS NS NS

6. Fundus Photos OD OS
OS photo demonstrates a 1-2 DD choroidal nevus with a CNVM juxtaposition to it extending into the fovea
Greenish fibrotic lesion,

7. IR Photos OD OS
OS photo demonstrates a 1-2 DD hyper-reflective lesion in the choroid
Hypointense area, non specific chronic changes under the area of retinal swelling
-speculed areas

8. FAF Photos OD OS
Hypoautofluoercent lesion 2 DD in the macula. And hyperautofluoercent signal surround.

9. OCT OD
Macula OS
Macula
Distorted contour of the fovea. Hyper-reflective materal subfoveal with CME above w/ subretinal fluid consistent with CNVM
OS photo demonstrates a subretinal fluid, w/ a CNVM, retinal thickening, and CME

10. OCT OS Below the Fovea OS Through the Nevus
IR photo: hyperintense on IR, and OCT shows hyper-reflective signal. Hypo-reflective on IR OCT. It is optically clear and why there is enhancement of the OCT signal

11. FA Late Phase Early Venous Phase 00:12:00 02:00:00
Middle see a NVM and a blocked flurescetn area with stiplling with hyperfluorescent stippling dots. After 2 mins you see a leak in the membrane area that is consistent area of window defect. Blocked flurescent (blood or fluid) and window defect (stippling)
--hyeperflurescent lesion..late you see leakage in the angio.classic CNVM
00:12:00
02:00:00

12. FA/ICG
Blockage, leakage, staining, and window defect (transmission defects)….Hypoflurescent..blocked fluorescent ICG, and blocked bc of fluid. Nevus also blocking the fluresecent. Cant see vasc connection between the 2 lesions
Demonstrates a well defined CNVM in the same location as the retinal leakage

13. Summary DDx: Choroidal neovascular membrane Idiopathic ? Nevus ?
59 y/o WM with decreased vision OS. Examination and FA reveal a choroidal neovascular membrane w/ a concomitant choroidal nevus
DDx:
Choroidal neovascular membrane
Idiopathic ?
Nevus ?
PLAN: Avastin injection with 1 month f/u

14. Exam s/p 2 Avastin Injections
VA TP P
20/20 (+1.25 sph)
20/300 (+1.75 sph) 16
3→2
no RAPD
EOM: full OU

15. OCT OS
Resolution of subretinal fluid and CME, but integrity of the outer retinal layer is diminished

16. OCT OS Below the Fovea OS Through the Nevus
Shadow and pigmentary changes over the prolonged edema
Resolution of subretinal fluid and CME, but integrity of the outer retinal layer is diminished, and below the fovea there is a PED

17. Cause of the CNVM Is it due to the choroidal nevus?
Or is it an idiopathic CNVM?

18. Complications of Choroidal Nevi
Naumann  GOHHellner  KNaumann  LR Pigmented nevi of the choroid: clinical study of secondary changes in the overlying tissues. Trans Am Acad Ophthalmol Otolaryngol.1971;75110- 123
Complications of Choroidal Nevi
Numerous studies postulate that the prevalence of choroidal nevi in the general population is anywhere from 0.2% - 30%
Most use 6.5% as the incidence of nevi in the general population
A total of 3654 subjects aged 49 to 97 years participating in the Blue Mountains Eye Study had a detailed eye examination, including photography of 6 standard retinal fields. Nevi were graded from photographs.
Results  Nevi were present in 6.5% of the population (n = 232), 
Sumich P, Mitchell P, Wang JJ. Choroidal nevi in a white population: the Blue Mountains Eye Study. Arch Ophthalmol May;116(5): PubMed PMID:

19. Complications of Choroidal Nevi
Naumann  GOHHellner  KNaumann  LR Pigmented nevi of the choroid: clinical study of secondary changes in the overlying tissues. Trans Am Acad Ophthalmol Otolaryngol.1971;75110- 123
Complications of Choroidal Nevi
Decreased visual acuity attributable to
Serous foveal detachment
Photoreceptor degeneration
CNVM
Blue Mountains Eye Study: None had complications associated with vision loss
A total of 3654 subjects aged 49 to 97 years participating in the Blue Mountains Eye Study had a detailed eye examination, including photography of 6 standard retinal fields. Nevi were graded from photographs.
Results  Nevi were present in 6.5% of the population (n = 232), 
Gonder JR, Augsburger JJ, McCarthy EF, Shields JA. Visual loss associated with choroidal nevi. Ophthalmology Aug;89(8): PubMed PMID:
Sumich P, Mitchell P, Wang JJ. Choroidal nevi in a white population: the Blue Mountains Eye Study. Arch Ophthalmol May;116(5): PubMed PMID:

20. Complications of Choroidal Nevi
22 of 206 patients (11%) with choroidal lesions had decreased VA attributable to :
Serous foveal detachment (50%)
Photoreceptor degeneration (42%)
CNVM (8%)
322 eyes with giant choroidal nevi, 2.2% had decreased vision
4100 choroidal nevus ID 322 (8%) of giant choroidal nevi > = 10mm
Gonder JR, Augsburger JJ, McCarthy EF, Shields JA. Visual loss associated with choroidal nevi. Ophthalmology Aug;89(8): PubMed PMID:
Li HK, Shields CL, Mashayekhi A, Randolph JD, Bailey T, Burnbaum J, Shields JA. Giant choroidal nevus clinical features and natural course in 322 cases. Ophthalmology Feb;117(2): doi: /j.ophtha Epub 2009 Dec 6. PubMed PMID:

21. Complications of Choroidal Nevi
Choroidal Nevus Risk Factors for Vision loss
Nevus proximity to foveola (0 mm vs > 0 mm): RR = 36.46
Subretinal fluid (> 3 to 6 mm vs none): RR =
RPE detachment (present vs absent):RR = 33.01
CNVM (present vs absent): RR = 98.72
4100 choroidal nevus ID 322 (8%) of giant choroidal nevi > = 10mm
Li HK, Shields CL, Mashayekhi A, Randolph JD, Bailey T, Burnbaum J, Shields JA. Giant choroidal nevus clinical features and natural course in 322 cases. Ophthalmology Feb;117(2): doi: /j.ophtha Epub 2009 Dec 6. PubMed PMID:
Shields CL, Furuta M, Mashayekhi A, Berman EL, Zahler JD, Hoberman DM, Dinh DH, Shields JA. Visual acuity in 3422 consecutive eyes with choroidal nevus. Arch Ophthalmol Nov;125(11): PubMed PMID:

22. Why the Difference Between the Studies
In the Blue Mountains Eye Study, the average diameter for the nevus was between 1-2mm, with 1.5% of them being over 4mm
Wills Eye 3,000+ patients with choroidal nevi have an average diameter of mm

23. Conclusion Is the CNVM secondary to the choroidal nevus?
Or is it just an idiopathic CNVM, and the choroidal nevus is just an innocent bystander
Choroidal nevi can cause decreased VA
Proximity to the fovea
Subretinal fluid
RPE detachment
CNVM

24. THANK YOU

25. References 5. Retina and Vitreous, BCSC
Ophthalmic Pathology and Intraocular Tumors, BCSC
American Academy of Ophthalmology eye wiki website on idiopathic CNVMs
Krypton laser photocoaguluation for idiopathic neovascular lesions: results of a randomized clinical trial. Photocoagulation Study Group. Arch Ophthalmol. 1990; 108:
Persistent and recurrent NV after krypton laser photocoagulation for NV lesion of ocular histoplasmosis. Macular Photocoagulation Study Group. Arch Ophthalmol. 1989; 107:
Kanski’s Clinical Ophthalmology A systemic Approach, Eighth Edition. Brad Bowling
Gonder JR, Augsburger JJ, McCarthy EF, Shields JA. Visual loss associated with choroidal nevi. Ophthalmology Aug;89(8): PubMed PMID:
D.G. Callanan, M.L. Lewis, S.F. Byrne, J.D.M. Gass Choroidal neovascularization associated with choroidal nevi Arch Ophthalmol, 111 (1993), pp. 789–794
Gass  JD Problems in the differential diagnosis of choroidal nevi and malignant melanoma: XXXIII Edward Jackson Memorial lecture. Trans Am Acad Ophthalmol Otolaryngol.1977;8319- 48
Ganley  JPComstock  GW Benign nevi and malignant melanomas of the choroid. Am J Ophthalmol. 1973;7619- 25
Naumann  G Pigmented nevi of the choroid and ciliary bodies: a clinical and histopathological study. Adv Ophthalmol. 1970;23187- 272
Hale  PNAllen  RAStraatsma  BR Benign melanomas (nevi) of the choroid and ciliary body. Arch Ophthalmol. 1965;74532- 538
Wilder  HC Intraocular tumors in soldiers: World War II. Mil Surg. 1946;99459- 490
Lang  GKDaumann  FJ Peripheral fundus changes in subjects with healthy eyes (pilots). Klin Monatsbl Augenheilkd. 1982;  495 Link to Article
Albers  EC Benign melanomas of the choroid and their malignant transformation. Am J Ophthalmol. 1940;23779- 783
Albert  DMRobinson  NLFulton  AB  et al.  Epidemiological investigation of increased incidence of choroidal melanoma in a single population of chemical workers. Int Ophthalmol Clin.1980;2071- 92
Albert  DMSearl  SSForget  BLavin  PTKirkwood  JNordlund  JJ Uveal findings in patients with cutaneous melanoma. Am J Ophthalmol. 1983;95474- 479
Rodriguez Sains  RS Ocular findings in patients with dysplastic nevus syndrome. Ophthalmology. 1986;93661- 665
Smith  REGanley  JP Ophthalmic survey of a community, I: abnormalities of the ocular fundus. Am J Ophthalmol. 1972;  1130
Sumich P, Mitchell P, Wang JJ. Choroidal nevi in a white population: the Blue Mountains Eye Study. Arch Ophthalmol May;116(5): PubMed PMID: 5.

26. Idiopathic CNVM
Is a disease of exclusion that can be made after all other causes associated with CNV have been ruled out:
Angioid streaks
High myopia
AMD
Chorioretinal inflammatory conditions
Tumors
Trauma

27. Idiopathic CNVM
Some speculate that it could represent POHS w/o the punched-out chorioretinal lesion
Other speculate that it could be a variant of AMD w/out drusen or RPE abnormalities
Krypton laser photocoaguluation for idiopathic neovascular lesions: results of a randomized clinical trial. Photocoagulation Study Group. Arch Ophthalmol. 1990; 108:
Persistent and recurrent NV after krypton laser photocoagulation for NV lesion of ocular histoplasmosis. Macular Photocoagulation Study Group. Arch Ophthalmol. 1989; 107: