Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Clinical Features and Multi-Modality Imaging of Isolated Retinal Astrocytic Hamartoma

Andrew W. Stacey, MD, MS; Tomas Ilginis, MD; Maria Pefkianaki, MD, PhD; Michael Michaelides, MD; Phill Hykin, MD; Andrew Webster, MD; Anthony T. Moore, MD; Mandeep S. Sagoo, MD

Abstract

BACKGROUND AND OBJECTIVE:

To identify the clinical and imaging characteristics of isolated retinal astrocytic hamartomas (IRAH).

PATIENTS AND METHODS:

A case series of eight patients diagnosed with IRAH.

RESULTS:

The average age at diagnosis was 32 years (range: 9 years to 80 years). After a median follow-up time of 59 months, none of the lesions had demonstrated any change or growth. Fundus fluorescein angiogram identified hyperfluorescence in five of six imaged lesions. Fundus autofluorescence (FAF) changes were seen in all eight cases. Ocular ultrasound was able to identify a lesion in only five of the seven cases. Optical coherence tomography (OCT) was able to document the tumor thickness and level of retinal invasion in all cases.

CONCLUSIONS:

Multimodal imaging is useful for the diagnosis and monitoring of IRAH. OCT and FAF are sensitivity tools for identifying IRA and can be used to follow the thickness and margins of these lesions.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:e1–e9.]

Abstract

BACKGROUND AND OBJECTIVE:

To identify the clinical and imaging characteristics of isolated retinal astrocytic hamartomas (IRAH).

PATIENTS AND METHODS:

A case series of eight patients diagnosed with IRAH.

RESULTS:

The average age at diagnosis was 32 years (range: 9 years to 80 years). After a median follow-up time of 59 months, none of the lesions had demonstrated any change or growth. Fundus fluorescein angiogram identified hyperfluorescence in five of six imaged lesions. Fundus autofluorescence (FAF) changes were seen in all eight cases. Ocular ultrasound was able to identify a lesion in only five of the seven cases. Optical coherence tomography (OCT) was able to document the tumor thickness and level of retinal invasion in all cases.

CONCLUSIONS:

Multimodal imaging is useful for the diagnosis and monitoring of IRAH. OCT and FAF are sensitivity tools for identifying IRA and can be used to follow the thickness and margins of these lesions.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:e1–e9.]

Introduction

Retinal astrocytic hamartomas are benign tumors of retinal astrocytes. Terminology of these lesions in the literature is inconsistent, but many authors use the terms “retinal astrocytic hamartoma” and “retinal astrocytoma” interchangeably. However, some have differentiated hamartomas from astrocytomas, with the astrocytoma being a more aggressive lesion.1 Retinal astrocytic hamartomas usually show clinical stability over long periods of follow-up.2 Rarely, they can show aggressive features such as vitreous seeding, retinal neovascularization, exudation, or even retinal detachment.3 Ophthalmoscopically, the hamartomas arise from the inner sensory retina and can be multiple or solitary, calcified or uncalcified.4 The uncalcified lesions are typically small, yellowish-grey lesions.2 The calcified lesions show glistening spherules of calcification. Larger lesions sometimes can be associated with adjacent retinal traction.5

Astrocytic hamartomas occur most commonly in association with tuberous sclerosis complex (TSC). TSC is a dominantly inherited disorder with a variable phenotype that includes brain astrocytoma, cutaneous angiofibromas, cutaneous depigmented macules (ash-leaf sign), renal angiomyolipoma, and other hamartomas.6 TSC is genetically heterogeneous with two major loci; 9q34 (TSC1), and 16p13 (TSC2). The gene at each locus has been identified, and both are tumor-suppressor genes. TSC1 encodes the protein hamartin and TSC2 encodes tuberin.

Retinal hamartomas are one of the major diagnostic features of TSC, occurring in about a third of patients.8,9 Occasionally, these tumors can present in the absence of TSC.10,11 In these circumstances, the diagnosis can be referred to as isolated retinal astrocytic hamartoma (IRAH), though it has been called various names in the literature, including solitary retinal astrocytoma, acquired retinal astrocytoma, isolated astrocytic hamartoma, astrocytic hamartoma of the retina not associated with TSC, atypical retinal astrocytic hamartoma, and spontaneous retinal astrocytoma.12 This entity should be distinguished from presumed solitary circumscribed retinal astrocytic proliferation (PSCRA), which appears in older patients and may arise from the middle layers of the retina.13,14

The diagnosis of IRAH is more problematic than retinal astrocytic hamartomas associated with TSC, as there are no other features to suggest an etiology of the retinal findings. Distinguishing IRAH from other causes of retinal tumors can be aided by modern retinal imaging. Here we present the clinical and imaging findings in eight patients IRAH without any family history or systemic features of TSC and highlight the key diagnostic features.

Patients and Methods

After approval from the institutional review board, we conducted a retrospective review of all patients who were evaluated at our tertiary care referral center and were diagnosed with isolated retinal astrocytoma. A retrospective review of patient records was conducted with variables of interest including age, race, gender, symptoms, VA, and physical exam findings. Details of the ocular examination included visual acuity (VA), symptoms, tumor location and dimensions, presence or absence of calcification, and associated retinal findings.

All available imaging studies were reviewed in each patient and included, where available, color fundus photography, fundus autofluorescence (FAF), fluorescein angiography (FA) (Spectralis HRA+OCT; Heidelberg Engineering, Heidelberg, Germany, or Optos 200 Tx; Dunfermline, Scotland), optical coherence tomography (OCT) (Spectralis HRA+OCT), and ocular ultrasound (US) (Acuson 512 scanner; Siemens, Malvern, PA); probes used were the 15L8 and 10V4).

Reflectance of the tumor mass on OCT was classified as “high” if equal to retinal nerve fiber layer (RNFL) or “medium” if equal to ganglion cell layer (GC). Presence or absence of calcification on US was assessed by the same experienced ultrasonographer and identified as a focal high reflectivity with shadowing of the deeper structures. Tumor height was measured on both OCT and US imaging studies. Measurements of the distance from the lesion to the optic disc or fovea were made using the autofluorescence images with built-in software from the Heidelberg Spectralis machine.

Results

Eight patients met inclusion criteria for the study. All patients had a unilateral, solitary retinal astrocytoma. The median age at diagnosis was 32 years (range: 9 years to 80 years). There were four males and four females. Of the eight cases, six (75%) patients were of Caucasian descent and two patients were of mixed race. Family history and systemic features of TSC were absent in all cases. One patient presented with blurred vision in the affected eye. In the other seven patients, the lesions were found incidentally on routine examination. The median follow-up time was 59 months (range: 0 months to 170 months). One patient was lost to follow-up after initial consultation and imaging. During that period of follow-up, there was no evidence of progression in any patient. Presenting VA ranged from 20/20 to 20/50 and remained the same throughout follow up in all patients (Table 1).

Demographic and Clinical Features on Presentation for All Patients

Table 1:

Demographic and Clinical Features on Presentation for All Patients

Clinical Appearance

On ophthalmoscopic examination, the lesions were located at the posterior pole in four eyes, next to the optic disc in three eyes, and in the periphery in one eye (Figure 1). Funduscopic examination in two patients demonstrated lesions with feathery appearance and indistinct borders (Patients 1 and 8), also known as Type I lesions.9 Two patients had a strictly solid, mulberry-type appearance (Type II lesions). The remaining four patients demonstrated a combination of solid and feathery appearance. None of these lesions demonstrated retinal hemorrhages or gross vitreous seeding on examination. In five eyes, calcification was noted clinically (Patients 2, 3, 5, 6, and 7).

Color fundus photographs of all patients upon presentation. Images are numbered corresponding to the patient labels consistent in other Tables and Figures.

Figure 1.

Color fundus photographs of all patients upon presentation. Images are numbered corresponding to the patient labels consistent in other Tables and Figures.

Fundus Autofluorescence

FAF was completed in all eight patients (Table 2, Figure 2). In all patients, the lesion was evident and mapped by a hypoautofluorescent lesion with variable hyperautofluorescent changes within the lesion. Measurements from these images demonstrated a median distance of closest tumor edge to the fovea to be 2.7 mm (range: 0.6 mm to 12.4 mm). The median distance to the optic nerve head was 1.1 mm (range: 0.0 mm to 9.5 mm). The median largest basal diameter of these lesions was 2.8 mm (range: 1.0 mm to 4.8 mm). Five patients showed elements of hyperautofluorescence within the tumors. In four of these patients, the hyperautofluorescence was bullous within the entire lesion. These areas have been speculated to be due to inner retinal cysts.15

Imaging Features of Isolated Astrocytic Hamartomas in All Patients in the Study

Table 2:

Imaging Features of Isolated Astrocytic Hamartomas in All Patients in the Study

Fundus autofluorescence of all patients upon presentation. Images are numbered corresponding to the patient labels consistent in other Tables and Figures.

Figure 2.

Fundus autofluorescence of all patients upon presentation. Images are numbered corresponding to the patient labels consistent in other Tables and Figures.

Fundus Fluorescein Angiography

Fundus fluorescein angiography (FFA) was completed in six patients (Table 2, Figure 3). In one lesion (Patient 5), there was no fluorescence and only subtle blockage from the lesion. In the other five lesions, there was early hyperfluorescence in the hamartoma. In three lesions there was late staining in the lesion. In two lesions, the FFA revealed late leakage. One lesion showed evidence of retinal vessels and intrinsic blood supply during the arterial phase (Patient 7). The vessels in this case were not dilated, differentiating this tumor type from feeder vessels in retinal capillary hemangioblastoma.

Fundus fluorescein angiography of six patients upon presentation. Images are numbered corresponding to the patient labels consistent in other Tables and Figures. Two patients did not undergo fluorescein angiogram (Patient No. 1 and No. 2).

Figure 3.

Fundus fluorescein angiography of six patients upon presentation. Images are numbered corresponding to the patient labels consistent in other Tables and Figures. Two patients did not undergo fluorescein angiogram (Patient No. 1 and No. 2).

Optical Coherence Tomography

OCT imaging was completed in seven patients with posterior pole tumors (Table 3, Figure 4). Five lesions were dome-shaped, whereas two were plaque-like. The plaque-like lesions had a solid structure. Three of the dome-shaped lesions had a cystic structure, whereas the other two had a solid structure. The hamartomas were present in the retinal nerve fiber layer of all eyes. The depth of the lesions varied. The lesions were located as deep as the inner plexiform layer in all eyes. In three eyes, the lesion appeared to involve the inner nuclear layer, and in one eye, the lesion appeared to involve all layers of the retina from the RNFL to the outer segments (Patient 4). All lesions showed evidence of shadowing; however, three lesions showed only minimal evidence of shadowing (those without calcification), whereas four lesions showed marked shadowing.

Ocular Coherence Tomography Characteristics of Isolated Astrocytic Hamartomas

Table 3:

Ocular Coherence Tomography Characteristics of Isolated Astrocytic Hamartomas

Ocular coherence tomography of all patients upon presentation. Images are numbered corresponding to the patient labels consistent in other Tables and Figures.

Figure 4.

Ocular coherence tomography of all patients upon presentation. Images are numbered corresponding to the patient labels consistent in other Tables and Figures.

Ophthalmic ultrasound of six of the eight patients upon presentation. Images are numbered corresponding to the patient labels consistent in other Tables and Figures. Patient No. 2 did not obtain an ultrasound, and Patient No. 8 had no detectable lesion on ultrasound.

Figure 5.

Ophthalmic ultrasound of six of the eight patients upon presentation. Images are numbered corresponding to the patient labels consistent in other Tables and Figures. Patient No. 2 did not obtain an ultrasound, and Patient No. 8 had no detectable lesion on ultrasound.

The tumor thickness was measurable with OCT in five patients. In two patients the tumor was too large for thickness measurement. Five lesions showed hyperreflective dots along the tumor surface, anterior to the RNFL, on the posterior vitreous face, or within the vitreous itself. These may represent simple calcification of the anterior portion of the tumor, but these hyperreflective dots have also been suggested to be a sign of vitreous seeding.15 The relative internal tumor reflectance on OCT was compared to the reflectance of RNFL and GCL; four lesions were isoreflective with GCL and three lesions were isoreflective with RNFL (Figure 4). There were no cases of subretinal fluid.

Ocular Ultrasound

US was completed in seven of the eight patients (Table 2, Figure 4). In two of these patients (Patients 1 and 8), the tumor was not detectable and could not be measured. In one patient (Patient 5) an area of high reflectance was noted in the region of the tumor, but no thickness was detected. All tumors identified with US demonstrated thickness larger than 1.0 mm. Of the five patients who had clinically evident calcification on exam, four underwent US and all of these showed US evidence of calcification. These calcified tumors represented the five oldest patients in the cohort. All patients older than 30 years of age had clinical evidence of calcification. All patients younger than 20 years had neither clinical nor US evidence of calcified tumor. The calcified tumors were found in the posterior pole, next to the optic nerve, and in the far periphery. Intrinsic blood flow was detected in one lesion (Patient 6).

Discussion

In this report we have documented the clinical and imaging characteristics of patients with IRAH.

Clinical Appearance

Some characteristics of IRAH have been reported to help differentiate this entity from the retinal astrocytic hamartomas seen with TSC. IRAHs are always solitary and have been reported to demonstrate less calcification and slower progressive growth than their counterparts associated with TSC2. In this series of eight patients, there was no progression of any lesion, and five of the eight patients were found to have clinically evident calcifications.

Our data support the theory that IRAHs are more likely to be diagnosed on routine exams and are more likely to be found in the posterior pole. In this series, seven of the eight patients were asymptomatic, and the same proportion had posterior pole tumors.

In this series, the presence of calcium appears to be related to the age of the patient. All patients with clinically evident calcifications were older than 30 years, whereas all patients without calcifications were younger than the age of 20. This finding supports other authors who have suggested that calcification of the tumors may occur over time, with most infants being found to have Type I tumors (feathery), whereas older patients have more solid tumors.16

Hamartomas of both the TSC and IRAH variety have been reported to progress rapidly and cause complications.3,17,18 None of the patients in this series demonstrated any of these findings on presentation or follow-up.

Imaging

Multimodality imaging is of paramount importance for the diagnosis of IRAHs. As these lesions have no systemic association, their diagnosis can be difficult, especially in subtle cases of Type I lesions. In studies of all retinal astrocytic hamartomas (isolated and TSC-associated), FAF19 and OCT16 have been shown to be very sensitive in diagnosis. In our series, all lesions detected clinically were also detected with FAF. OCT was able to document all lesions in the posterior pole.

FAF is a very useful tool in the diagnosis, measurement, and monitoring of these lesions. FAF provides a very sensitive test of lesion detection and can also readily map the lesion for long-term monitoring. This provides the best method of enface measurement of these, often pale, astrocytic hamartoma borders. The presence of hyperautofluorescence within the lesions appears to be due to intraretinal cysts.15

Fluorescein angiography has been suggested as the best method for evaluating IRAH vascularity.15 In this series, FFA was useful in identifying intrinsic vascularity in one patient and did identify leakage in two patients. However, it showed only faint blockage without fluorescent changes in one patient. FFA remains an important part of the diagnosis and treatment planning for these lesions, especially if they are indeterminate or if they begin to progress. In contrast to retinal capillary hemangioblastomas, astrocytic hamartoma feeder vessels are not dilated.

OCT is a hallmark for diagnosis and monitoring of astrocytic hamartomas. The OCT results in this series are consistent with the OCT results reported by Shields et al. in a series of retinal astrocytic hamartomas of both isolated and TSC etiologies.20 There do not appear to be any findings intrinsically different on OCT between IRAHs and those associated with TSC.

OCT can also provide clues toward vitreous adhesion and traction on the tumor surface, as well as vitreous seeding of the tumor. In this series, only one patient had evidence of vitreous adhesion to the tumor without evidence of traction. Though no vitreous seeds were clinically evident, five patients did have evidence of hyperreflective dots in the vitreous or the posterior vitreous face on OCT. These warrant close observation for future vitreous seeding.

In this study, OCT was able to measure the thickness of small lesions not detectable by US. These measurements are likely more accurate, as the US tends to overestimate thickness in these patients in our dataset. However, not all lesions can be monitored by OCT. Peripheral lesions cannot be captured, and larger lesions may be too large for the OCT window. In these situations, thickness should be monitored by US. OCT angiography is an exciting new imaging modality and may also be useful in the diagnosis of these lesions.21

Ocular US plays an important role in initial diagnosis, as well as in identifying and verifying calcification. In this series, all patients who had clinical suspicion of calcification had verified calcification on US. This calcification appears to be related to the patient's age, as all calcified tumors occurred in patients older than 30 years of age.

The management of IRAHs remains close observation. Rarely, intervention may be required when progression occurs. Multimodality imaging is important in the initial diagnosis and long-term monitoring of these lesions. The characteristics demonstrated here can be helpful when diagnosing, monitoring, and assessing progression in these rare tumors.

References

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Demographic and Clinical Features on Presentation for All Patients

Demographic Data Findings on Presentation
Patient No. Age (At Presentation; Years) Follow-Up (Months) Gender Race Visual Acuity Lesion Appearance Retinal Hemorrhage Vitreous Seeds (Gross) Location*
1 20 0 F White 20/30 Type I No No PP
2 80 107 M Mixed 20/40 Type III No No PP
3 30 170 F White 20/30 Type II No No Periph
4 9 60 F White 20/20 Type III No No PP
5 34 46 M White 20/20 Type III No No ON
6 57 58 M White 20/20 Type III No No ON
7 36 64 F White 20/20 Type II No No PP
8 20 54 M Mixed 20/60 Type II No No ON

Imaging Features of Isolated Astrocytic Hamartomas in All Patients in the Study

Patient No. Autofluorescence Fluorescein Angiogram Ultrasound
Hyper/Hypoautofluorescense Largest Basal Diameter (mm) Distance to Fovea (mm) Distance to Optic Nerve (mm) Early Fluorescein Pattern Late Fluorescein Pattern Intrinsic Vasculature Feeder Vessels Detectable Calcifications Blood Flow Height (mm)
1 Hypo 2.2 1.5 3.2 - - - - No No No 0.0
2 Hyper 2.8 0.6 1.2 - - - - - - - -
3 Hyper 3.7 12.4 9.5 Hyperfluorescence Staining No No Yes Yes No 1.5
4 Dots 4.8 2.6 6.0 Hyperfluorescence Staining No No Yes No No 1.3
5 Hypo 1.0 4.2 0.0 No fluorescence Blockage No No Yes Yes No 0.0
6 Hyper 2.8 2.9 0.0 Hyperfluorescence Late blockage No No Yes Yes Yes 2.0
7 Hyper 3.4 3.8 9.9 Hyperfluorescence Staining Yes Yes Yes Yes No 1.5
8 Hypo 2.1 1.0 0.0 Hyperfluorescence Late leakage No No No No No 0.0

Ocular Coherence Tomography Characteristics of Isolated Astrocytic Hamartomas

Patient No. Height (mm) Solid or Cystic Subretinal Fluid Intraretinal Cysts Vitreous Adhesion Isoreflective With? Shape Retinal Layers Involved Hyperreflective Dots Shadowing
1 0.6 Solid No Yes No RNFL Plaque RNFL to IPL Yes Minimal
2 Too thick Cystic No Yes No RNFL Dome RNFL to INL No Yes
3 Unable - - - - - - - - -
4 0.5 Solid No No No GCL Plaque RNFL to IS/OS Yes Minimal
5 0.4 Solid No No No GCL Dome RNFL to IPL No Yes
6 Too thick Cystic No Yes No GCL Dome RNFL to IPL Yes Yes
7 1.1 Cystic No Yes No RNFL Dome RNFL to IPL Yes Yes
8 0.7 Solid No No Yes GCL Dome RNFL to INL Yes Minimal
Authors

From Ocular Oncology Service, Moorfields Eye Hospital, London (AWS, MP, MSS); the Department of Ophthalmology, University of Washington, Seattle (AWS); Ocular Oncology Service, Wills Eye Hospital, Philadelphia (MP); Medical Retina Service, Moorfields Eye Hospital, London (TI, MM, PH, AW, ATM, MSS); University College London Institute of Ophthalmology, London (MM, AW, ATM, MSS); and the Department of Ophthalmology, University of California — San Francisco, San Francisco (ATM).

Dr. Stacey was funded in part by an unrestricted grant to the Department of Ophthalmology at the University of Washington from Research to Prevent Blindness. The remaining authors report no relevant financial disclosures.

Address correspondence to Andrew W. Stacey, MD, MS, Box 359608, 325 Ninth Ave., Seattle, WA 98104; email: awstacey@uw.edu.

Received: March 22, 2018
Accepted: May 04, 2018

10.3928/23258160-20190129-12

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