case report shaggy photoreceptors with subfoveal fluid...

Case ReportShaggy Photoreceptors with Subfoveal Fluid Associatedwith a Distant Choroidal Melanoma

Ann Q. Tran,1 James A. Eadie,2 and Michael M. Altaweel1

1Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI 53705, USA2Retina Vitreous Consultants, Pittsburgh, PA 15213, USA

Correspondence should be addressed to Ann Q. Tran; [email protected]

Received 16 October 2014; Accepted 22 January 2015

Academic Editor: Cristiano Giusti

Copyright © 2015 Ann Q. Tran et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose. To describe the enhanced depth imaging optical coherence tomography (EDI-OCT) findings in a patient with an extramacula choroidal melanoma before and after treatment.Methods. Observational case report. Results. A 45 year-old Caucasian malepatient was referred to retina clinic for management of choroidal melanoma. Examination revealed a nasal choroidal melanomawhile EDI-OCT illustrated subfoveal fluid pocket with elongated shaggy photoreceptors distant and separate from the tumor. Thepatient was treated with plaque brachytherapy and intravitreal bevacizumab. One week after plaque removal, there was a dramaticreduction in the shaggy photoreceptors. Conclusion. Choroidal melanomas have effects that are not localized to the area of thetumor. This loculated pocket of subretinal fluid and coinciding changes to photoreceptor morphology may be related to globalchanges in choroidal function or release of tumor related cytokines.

1. Introduction

The term “shaggy photoreceptors” has been used to describedistinct morphological changes, specifically swelling andelongation of the outer retina as seen on enhanced depthimaging-optical coherence tomography (EDI-OCT). Thisfinding was first described in central serous chorioretinopa-thy in 2008 [1] and in sympathetic ophthalmia in 2011[2]. It was later appreciated in choroidal melanomas andchoroidal metastases [3, 4] and has been shown to be afeature that distinguishes small melanomas from choroidalnevi [5]. We report a case of an extra macular choroidalmelanoma producing a distant subfoveal pocket of fluidwith shaggy photoreceptors. The appearance of the outerretina improved following radioactive plaque therapy andintravitreal bevacizumab injection.

2. Case Presentation

A 45 year-old Caucasian man presented with a one-monthhistory of painless decrease in vision, photopsia, and meta-morphopsia. The patient’s best-corrected visual acuity was20/300 OD and 20/20 OS. On dilated exam, he was found

to have a medium sized nasal choroidal melanoma andlarge inferior serous retinal detachment in his right eye(Figure 1(a)). The patient’s macula was remarkable for sub-retinal fluid and striae that did not communicate with theserous retinal detachment inferiorly. B-scan ultrasonographydemonstrated a dome shaped choroidal lesion with lowinternal reflectivity (Figure 1(b)). Tumor base measurementswere 9.37 × 13.63mm with a height of 7.90mm withoutextrascleral extension. EDI-OCT of the macula confirmedthe presence of an isolated pocket of subfoveal fluid (Spec-tralis OCT (Heidelberg Engineering GmbH, Heidelberg,Germany); Figure 2(a)). The outer retina was remarkable forshaggy photoreceptors, subretinal lipofuscin precipitates, anda hyperreflective outer plexiform layer.

Three weeks after diagnosis, an 18mm radioactive plaquewas placed on the right eye and was removed 5 days later.Intravitreal bevacizumab (Avastin; Genentech, San Fran-cisco, CA) was given at the time of plaque placement. At theone-week postoperative office visit following plaque removal,best-corrected visual acuity had improved to 20/125 OD.EDI-OCT of the macula showed persistent subfoveal fluid,resolution of subretinal lipofuscin precipitates, and dramaticvolume reduction in shaggy photoreceptors (Figure 2(b)). At

Hindawi Publishing CorporationCase Reports in Ophthalmological MedicineVolume 2015, Article ID 187542, 3 pageshttp://dx.doi.org/10.1155/2015/187542

2 Case Reports in Ophthalmological Medicine

(a) (b)

Figure 1: Appearance of the nasal choroidal melanoma (a) and B-scan ultrasonography with some vascularity and low reflectivity but noextrascleral extension (b).

(a)

(b)

(c)

(d)

Figure 2: Optical coherence tomography scans of the fovea before(a) and one week after treatment showing reduced volume of shaggyphotoreceptors (b). At six weeks, there is recurrent subretinal fluidwith presence of shaggy photoreceptors (c) which again resolvedfour months later (d).

the six-week followup, his visual acuity remained stable at20/125 OD. EDI-OCT showed a stable volume of subretinalfluid with potential recurrence of the shaggy photoreceptorsin the outer retina (Figure 2(c)).Thepatient opted to continue

with observation versus a repeat intravitreal injection ofbevacizumab. At the four-month followup, his best correctedvisual acuity was 20/150 OD. Tumor height decreased to6.05mm. EDI-OCT demonstrated resolution of subretinalfluid and compressed shaggy photoreceptors (Figure 2(d)).

3. Discussion

We report a case of a peripheral nasal choroidal melanomanot involving the macula that produced distant subfovealfluid and shaggy photoreceptors demonstrated by EDI-OCT.Shaggy photoreceptors appear elongated and irregular. Ithas been hypothesized that morphological change is dueto an incompletely understood effect that the subretinalfluid has on the photoreceptors. This feature was initiallydescribed in central serous chorioretinopathy, where themean length of photoreceptor outer segments measuring50 𝜇m in the area of subretinal fluid versus the norm of 30 𝜇min unaffected eyes [6]. More recently, shaggy photoreceptorshave been observed in the subretinal fluid overlaying bothchoroidal melanomas and choroidal metastases [3–5]. Theywere not observed in eyes with choroidal nevus and overlyingsubretinal fluid, providing an important feature that assists indistinguishing small melanoma from nevus.

In this case, the subretinal fluid and the shaggy photore-ceptors are observed in a localized pocket under the foveaand distant from the tumor itself. The etiology of this fluid isunclear although its presence is potentially indicative of somecombination of changes to choroidal permeability, changes toretinal pigment epithelial function, and changes to circulatingcytokines related to or produced by the tumor. As therewas a serous retinal detachment adjacent to the choroidalmelanoma, the subretinal fluid may be explained by trackingfrom the tumor itself. During I-125 plaque placement, intrav-itreal bevacizumab was administered, resulting in resolutionof the subretinal fluid and improvement in the appearance ofthe photoreceptors at the two-week postoperative assessment.After four months the shaggy photoreceptors were againpresent, in association with subfoveal fluid.

The reduction in volume of the shaggy photoreceptorsmay be related either to the effect of intravitreal bevacizumab

Case Reports in Ophthalmological Medicine 3

administration or to the brachytherapy. Both treatmentscan result in reduction of subretinal fluid associated withmelanoma, and the resolution of the subretinal fluid may becorrelated with normalization of photoreceptor appearance.There appears to be a spectrum of photoreceptor changesin association with subretinal fluid. The acute presence ofsubretinal fluid in this setting results in photoreceptor cellularedema which leads to the appearance of shaggy photore-ceptors. When the subretinal fluid is chronically present,the photoreceptor layer atrophies. The loss of the this layerevident on spectral domain OCT, and it has been thoughtthat the shaggy photoreceptors became more granulated andeventually shed [3, 4].

Improvement of shaggy photoreceptors has beenreported in patients treated for choroidal metastases [4] andhas been associated with resolution of subretinal fluid. Thiscase of choroidal melanoma with subfoveal fluid distant fromthe lesion demonstrated shaggy photoreceptors that wereno longer evident when the subretinal fluid was eliminatedand recurred when subretinal fluid reaccumulated. Thiscase adds to the finding that choroidal melanoma withoverlying subretinal fluid may be associated with shaggyphotoreceptors. Such irregular elongated photoreceptors canbe found in distant pockets of subretinal fluid associated withthe melanoma. This has not been described with choroidalnevus and therefore serves as a distinguishing factor insuspicious cases.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

References

[1] H. Matsumoto, S. Kishi, T. Otani, and T. Sato, “Elongation ofphotoreceptor outer segment in central serous choroiretinopa-thy,”American Journal of Ophthalmology, vol. 145, no. 1, pp. 162–168, 2008.

[2] V. Gupta, A. Gupta, M. R. Dogra, and I. Singh, “Reversibleretinal changes in the acute stage of sympathetic ophthalmiaseen on spectral domain optical coherence tomography,” Inter-national Ophthalmology, vol. 31, no. 2, pp. 105–110, 2011.

[3] M. L. Repucci, D. Rojanpom, and C. L. Shields, “Shaggyphotoreceptors with small choroidal melanoma,” Retina Today,vol. 7, pp. 45–47, 2012.

[4] H. Demirci, A. Cullen, and J. M. Sundstrom, “Enhanced depthimaging optical coherence tomography of choroidalmetastasis,”Retina, vol. 34, pp. 1354–1359, 2013.

[5] C. L. Shields, S. Kaliki, D. Rojanaporn, S. R. Ferenczy, andJ. A. Shields, “Enhanced depth imaging optical coherencetomography of small choroidal melanoma: comparison withchoroidal nevus,” Archives of Ophthalmology, vol. 130, no. 7, pp.850–856, 2012.

[6] H.Matsumoto, S. Kishi, T. Sato, and R.Mukai, “Fundus autoflu-orescence of elongated photoreceptor outer segments in centralserous chorioretinopathy,” American Journal of Ophthalmology,vol. 151, no. 4, pp. 617–623, 2011.

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