Journal of Ophthalmology & Clinical Research Category: Clinical Type: Case Report
Management of Optic Disc Melanocytoma Associated with Choroidal Neovascularisation and Macular Detachment
- Vaishnavi Batmanabane1*, Manoj Soman1, Unnikrishnan Nair1
- 1 Department Of Retina And Vitreous, Chaithanya Eye Hospital And Research Institute, Kesavadasapuram, Trivandrum, Kerala 695004, India
*Corresponding Author:Vaishnavi Batmanabane
Department Of Retina And Vitreous, Chaithanya Eye Hospital And Research Institute, Kesavadasapuram, Trivandrum, Kerala 695004, India
Received Date: Nov 10, 2015 Accepted Date: Dec 10, 2015 Published Date: Dec 24, 2015
Ocular melanocytoma arises from the melanocytes of the Retinal Pigment Epithelium (RPE) and are usually located in the posterior pole. Often the full histopathological extent of the lesion might not be immediately obvious as it burrows beneath the retinal layers well past its exposed surface. This lesion has also been called a magnocellular nevus of the optic disc, stressing its benign nature.
Most melanocytomas are situated on the optic disc and if the patient is fortunate, will remain unobtrusive. Melanocytomas are rarely associated with secondary Choroidal Neovascular Membranes (CNVM) which may develop as a result of the neoplastic process breaching the integrity of the RPE. Once commenced, the neovascular process can threaten the fovea depending on its location. Subretinal haemorrhage and exudation will follow the occurrence of a CNVM, often causing a drastic worsening in vision. Different methods of managing CNVM in melanocytoma have been reported, ranging from photodynamic therapy to submacular surgery [12-14]. The discovery of anti-vascular Endothelial Growth Factor (VEGF) molecules has been a boon to the management of sight threatening intraocular neovascular processes. These agents target VEGF receptors, ultimately causing a decrease in angiogenesis. The current therapeutic benefit of anti-VEGF drugs like ranibizumab is that these agents can attack the inciting angiogenic factors without much collateral damage, yet as it is an invasive procedure, absolute certainty of the diagnosis and the benign nature of the lesion is necessary before the decision to treat with intravitreal injections is made.
We present the case of a 29 year old lady with an incidental melanocytoma of the optic disc and secondary CNVM, managed with intravitreal ranibizumab (Lucentis). The images that were obtained detailed the tracking of the melanotic pigments subretinally during and following treatment.
The patient was treated with 1.25mg of intravitreal injection ranibizumab (Lucentis) 0.05ml in view of the active CNVM. One week after the injection, the subretinal haemorrhage and fibrin had diminished with the resolution of most of the SRF, leaving a small residual amount around the optic disc (Figures 3a-d). Her vision had improved to 6/6 in OS. Interestingly, we observed that there was a migration of pigments toward the fovea and inferiorly with the resolution of the fluid imaged with the SD-OCT and autofluorescence imaging (Figures 4a and b). At last follow up 6 months later, her BCVA was 6/6 in both eyes with fundus of OS showing a scarred CNVM with no subretinal fluid under the fovea, persistent disc edema and dispersed pigments from the exposed melanocytoma. The dimensions of the melanocytoma were constant with no change in size noted.
The results after the first injection were encouraging with a 2 line visual improvement and clinical resolution of the subretinal fluid confirmed by OCT. Of concern was the migration of the pigment in the subretinal space, toward the fovea, which was a risk that had to be taken. This tracking was well imaged by autofluorescence imaging. As there has been subjective improvement in vision and clinical improvement with regard to the CNVM, we can assume that intravitreal ranibizumab had achieved the therapeutic goal in this patient.
The clinical dilemma of whether a pigmented optic disc lesion is malignant or not can be resolved by correlating clinical features and advanced imaging techniques like SD-OCT. This will determine the decision of how to treat the secondary neovascular processes. In conclusion, we report that appropriate imaging and intravitreal anti-VEGF agents may be considered to manage secondary CNVM in cases of optic disc melanocytoma, with good therapeutic outcomes.
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Citation:Batmanabane V, Soman M, Nair U (2015) Management of Optic Disc Melanocytoma Associated with Choroidal Neovascularisation and Macular Detachment. J Ophthalmic Clin Res 2: 017.
Copyright: © 2015 Vaishnavi Batmanabane, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.