A 50-year-old female patient presented to the Ophthalmology Department of the İstanbul University İstanbul Faculty of Medicine with an approximately 2-year history of gradual vision loss in her left eye. Despite progressively decreasing vision in her left eye over the course of 2 years, she had not previously consulted any doctor about the problem. There was nothing extraordinary in the patient’s medical or family history. Her vision was 1.0 (decimal) in the right eye and 0.05 in the left eye. Anterior segment examination was normal and intraocular pressure was 15 mmHg in the right eye and 16 mmHg in the left eye. Pigment epithelium changes were observed in both the right and left macula on fundoscopy (). OCT examination revealed extrafoveal inferonasal choroidal excavation in the right eye (), while in the left eye subfoveal focal choroidal excavation was observed, as well as separation of the retinal pigment epithelium (RPE) photoreceptor layer and subretinal fluid in the same area (). Central foveal thickness was 245 µm in the left eye. Fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) revealed hyperfluorescence consistent with pigment epithelium window defect in the macula and temporal quadrant of the right eye, and hyperfluorescence starting in the early phase and increasing in the late phases in the left macula (). The patient was diagnosed with chronic CSCR and her left eye was treated with low-fluence photodynamic therapy (PDT) (25 j/cm2, 300 mW/cm2). The spot size was adjusted targeting the area of choroidal vascular hyperpermeability observed in the ICGA mid-phase from which the subretinal fluid originated.\nAt 1 month after PDT, the subretinal fluid had resolved and visual acuity was 0.3. After 18 months of follow-up, no changes were observed in the lesions in the right eye, visual acuity in the left eye as maintained and there was no recurrence of subretinal fluid. OCT at the final examination showed continuity of the RPE and photoreceptor layer in the area of focal choroidal excavation, and no subretinal fluid was observed (). On FFA, the hyperfluorescence due to RPE window defect was not evident () and there was no active leakage apparent on ICGA ().
A 32-year-old female presented with decreased central vision in the right eye to our tertiary eye center (Khatam Eye Hospital) affiliated to Mashhad University of Medical Sciences. Institutional review board approval was obtained for this case report. Complete ophthalmic examination was done. BCVA was 20/100 on the right and 20/20 on the left one. Ophthalmoscopy revealed bilateral multifocal yellow-orange elevated choroidal masses with distinct borders at the posterior pole. The left eye was conspicuous in its macular tumor as well as juxtapapillary foci, indicative of multifocal nature of the lesion ().\nFundus autofluorescence (FAF) images revealed the calcified parts of the tumor to be isoautofluorescent (AF) or mild hyper-AF on the left, whereas the lesion was variable (hypo-hyper AF) on the right side, possibly due to RPE changes, which in turn stemmed from decalcification, CNV, and subretinal fluid (SRF) (). Fluorescein angiography (FAG) demonstrated variable hyperfluorescence of the tumor on both sides as well as CNV in the right eye (). Indocyanine green angiography (ICG), in early to mid-phase, showed the well-defined tumor to be hypofluorescent with CNV on the right side ().\nB-scan ultrasonography (NIDEK Echo scan US-4000, Gamagori, Japan) indicated hyperechogenicity of the tumor on both sides. Enhanced depth imaging optical coherence tomography (EDI-OCT) (Spectralis HRA + OCT, Heidelberg Engineering, Heidelberg, Germany) disclosed the thinning of choriocapillaries as well as large choroidal vessels, which were invisible in the calcified parts. Outer retinal abnormalities were attributed to CNV in the right eye. These regions also showed the disturbance of the outer retinal layers whereas the inner retina turned out to be entirely intact. The tumor displayed smooth undulating surface with horizontal layered hyperreflective lines in the tumor (). Orbital computerized tomography (CT) scan showed hyperdense plaques, with bone like homogeneity in the posterior pole. Two plaques were seen in the left eye ().\nThe final diagnosis of bilateral multifocal choroidal osteoma in association with CNV in the right eye was made based on multimodal imaging findings. The decalcified portion of tumor on the right was yellowish-white in color.\nThe safe conclusion pertaining to the above details was suggestive of the trend whereby tumor calcification and CNV had led to visual loss on the right eye. Thus, the patient received injections of intravitreal bevacizumab (Avastin, Genentech Inc., San Francisco, CA) in the right eye, which subsequently improved the BCVA to 20/40. This BCVA sustained during nine months of follow-up.