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Visual Acuity in 3422 Consecutive Eyes with Choroidal Nevus

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Visual Acuity in 3422 Consecutive Eyes with Choroidal Nevus CLINICAL SCIENCES Visual Acuity in 3422 Consecutive Eyes With Choroidal Nevus Carol L. Shields, MD; Minoru Furuta, MD; Arman Mashayekhi, MD; Edwina L. Berman, MBBS; Jonathan D. Zahler, DO; Daniel M. Hoberman, BS; Diep H. Dinh, BS; Jerry A. Shields, MD Objective: To evaluate visual acuity in eyes with cho- foveolar choroidal nevus, respectively. By multivariate roidal nevus. analysis, factors predictive of visual loss of 3 or more log- MAR lines included subfoveolar nevus location (rela- Design: This was an observational case series. Of 3422 tive risk [RR], 15.52), juxtapapillary nevus location (RR, consecutive eyes with choroidal nevus, vision loss at 15 4.52), initial visual acuity of 20/50 or worse (RR, 15.40), years occurred in 2% of eyes with extrafoveolar nevus overlying retinal pigment epithelial detachment (RR, and in 26% of eyes with subfoveolar nevus, particularly 22.16), and foveal edema (RR, 9.02). Factors predictive those with overlying retinal pigment epithelial detach- of poor final visual acuity of 20/200 or worse included ment and foveal edema. A retrospective medical record subfoveolar nevus location (RR, 11.32), overlying or- review was conducted, with evaluation of visual acuity ange pigment (RR, 3.68), overlying retinal pigment at presentation and at final examination. The main out- epithelial detachment (RR, 12.80), and foveal edema (RR, come measure was visual acuity. 18.72). Results: The median visual acuity at presentation was Conclusion: Mild vision loss over many years should be 20/20 for eyes with either extrafoveolar or subfoveolar choroidal nevus. Using Kaplan-Meier estimates, vision anticipated in patients with subfoveolar choroidal ne- loss of 3 or more logarithm of the minimum angle of reso- vus, particularly those with overlying retinal pigment epi- lution (logMAR) lines at 5, 10, and 15 years occurred in thelial detachment, orange pigment, and foveal edema. less than 1%, 1%, and 2% of eyes with extrafoveolar ne- vus compared with 15%, 20%, and 26% of eyes with sub- Arch Ophthalmol. 2007;125(11):1501-1507 HOROIDAL NEVUS IS THE and found 22 (11%) with visual acuity loss. most common clinically The vision loss was because of subfoveal detected intraocular tu- fluid (50%), presumed photoreceptor de- mor.1,2 In the Blue Moun- generation (42%), and choroidal neovas- tains Eye Study,3 choroi- cularization (8%).8 In 2005, Shields and as- Cdal nevi were found in 7% of the white sociates11 evaluated optical coherence population. This benign tumor manifests as tomography (OCT) of the retina overlying a pigmented or nonpigmented mass deep 120 consecutive patients with choroidal ne- to the retina, often with overlying drusen vus to better ascertain the reasons for vi- and retinal pigment epithelial (RPE) alter- sual loss and found overlying retinal edema ations.1-7 Choroidal nevus can produce cen- (15%), photoreceptor attenuation (51%), tral vision loss and peripheral visual field retinal thinning (22%), subretinal fluid loss.4,8-11 Rarely, choroidal nevus can evolve (26%), and RPE detachment (12%). In this into malignant melanoma.7,12-18 report, we analyze a large cohort of 3422 Visual field defects were documented in eyes with stable choroidal nevus to ascer- 38% of 42 eyes with choroidal nevus evalu- tain initial and final visual acuity, loss of vi- ated by Tamler and Maumenee4 and in 85% sual acuity over time, and factors related to of 21 eyes analyzed by Flindall and Drance10 visual acuity outcomes. using static and kinetic techniques. In 1971, Naumann and associates6 found central vi- Author Affiliations: Ocular METHODS Oncology Service, Wills Eye sual acuity loss in 13 of 124 eyes (10%) with 8 Institute, Thomas Jefferson choroidal nevus. Gonder and coworkers University, Philadelphia, later described 206 patients with choroi- A retrospective medical record review was Pennsylvania. dal nevi posterior to the equator of the eye performed on all patients with the clinical (REPRINTED) ARCH OPHTHALMOL / VOL 125 (NO. 11), NOV 2007 WWW.ARCHOPHTHALMOL.COM 1501 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Table 1. Choroidal Nevus in 3422 Eyes of 3187 Patients: Comparison of Clinical Features at Initial Examination for Extrafoveolar vs Subfoveolar Nevus Location of Choroidal Nevusa Clinical Feature Extrafoveolar Subfoveolar Age, y (n=3187)b 60 (62±15) [4-97] 58 (60±18) [4-93] Race (n=3187) White 2945 (98.5) 196 (99.0) African American 21 (0.7) 0 Hispanic 16 (0.5) 2 (1.0) Asian 6 (0.2) 0 Asian Indian 1 (0.03) 0 Sex (n=3187) Male 1095 (36.6) 75 (37.9) Female 1894 (63.4) 123 (62.1) Symptoms (n=3422) Decreased vision 160 (5.0) 62 (30.2) Visual field defect 33 (1.0) 5 (2.4) Photopsia or floaters 140 (4.4) 11 (5.4) None 2884 (89.6) 127 (62.0) Snellen visual acuity (logMAR) (n=3422) 20/20-20/40 (0-0.3) 2984 (92.8) 154 (75.1) 20/50-20/100 (0.4-0.7) 178 (5.5) 39 (19.0) 20/200 or worse (Ն 1.0) 55 (1.7) 12 (5.9) Tumor base, mm (n=3422)b 5.1 (5.0±2.8) [0.4-20.0] 5.7 (4.5±3.8) [1.0-24.0] Tumor thickness, mm (n=3422)b 1.6 (1.5±0.5) [0.6-4.5] 1.7 (1.6±0.5) [0.7-3.5] Tumor color (n=3422) Pigmented 2460 (76.5) 169 (82.4) Nonpigmented 347 (10.8) 27 (13.2) Mixed 410 (12.7) 9 (4.4) Related retinal or RPE findings (n=3422) Foveal edema 11 (0.3) 14 (6.8) Retinal invasion 5 (0.2) 1 (0.5) Subretinal fluid 285 (9.0) 60 (29.3) Subfoveal fluid 57 (1.8) 37 (18.0) Orange pigment 185 (5.8) 53 (25.9) RPE hyperplasia 240 (7.6) 9 (4.4) RPE detachment 33 (1.0) 9 (4.4) RPE fibrous metaplasia 252 (7.9) 11 (5.4) RPE atrophy 356 (11.2) 12 (5.9) Drusen 1735 (54.7) 84 (41.0) Choroidal neovascularization 13 (0.4) 7 (3.4) Abbreviations: logMAR, logarithm of the minimum angle of resolution; RPE, retinal pigment epithelium. a Data are given as number (percentage) of each group unless otherwise indicated. Percentages may not total 100 because of rounding. For the extrafoveolar group, n=2989 eyes for race and sex; n=3217 eyes for symptoms, Snellen visual acuity, and tumor color; and n=3172 eyes for related retinal/RPE findings. For the subfoveolar group, n=198 for race and sex; and n=205 for symptoms, Snellen visual acuity, tumor color, and related retinal/RPE findings. b Data are given as mean (median±SD) [range]. diagnosis of choroidal nevus evaluated at the Ocular Oncol- distance of the tumor margin to the optic disc margin and ogy Service at Wills Eye Institute between April 1, 1970, and foveola (in millimeters), largest tumor basal dimension and June 1, 2006. Institutional review board approval was thickness (in millimeters), tumor color (pigmented, mixed, or obtained for this retrospective study. Patients with evidence of nonpigmented), and presence of amelanotic halo around the tumor transformation into melanoma were not included in nevus (halo nevus). Other related data included subretinal the analysis. Clinical data were collected at initial examination fluid, orange pigment, drusen, RPE alterations (hyperplasia, regarding patient age, race, sex, medical history (dysplastic detachment, fibrosis, and atrophy), and choroidal neovascular nevus syndrome; cutaneous, choroidal, or conjunctival mela- membrane. The status of the foveola (involvement with noma; or neurofibromatosis), ocular melanocytosis, symp- underlying choroidal nevus, subretinal fluid, and retinal toms, and best-corrected visual acuity by Snellen charts. edema) was recorded. The final best-corrected visual acuity at Vision data were evaluated using logarithm of the minimum date last seen was recorded. angle of resolution (logMAR) conversion. Data regarding spe- A series of univariate Cox proportional hazards regressions cific features of the tumor were collected from large detailed assessed the degree of relationship of all of the variables previ- fundus drawings that were made of each patient at first exami- ously listed to 3 outcomes, including the initial visual acuity, nation and from fundus photographs. These data included final visual acuity, and visual acuity loss of 3 or more logMAR tumor epicenter quadrantic location (inferior, temporal, supe- lines. All of the variables were analyzed as discrete variables rior, nasal, or macular), tumor epicenter anteroposterior loca- except for patient age at presentation, tumor basal dimension, tion (macular, macular to equator, or equator to ora serrata), tumor thickness, and distance of the tumor to the optic disc (REPRINTED) ARCH OPHTHALMOL / VOL 125 (NO. 11), NOV 2007 WWW.ARCHOPHTHALMOL.COM 1502 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 A B Figure 1. Clinical appearance of pigmented extrafoveolar (A) vs pigmented subfoveolar (B) nevus in eyes without overlying retinal or retinal pigment epithelial changes (the visual acuity was 20/20 in both eyes). margin and foveola, which were evaluated as continuous vari- ables. Subsequent multivariate models included variables that Table 2. Choroidal Nevus in 2334 Eyes: Comparison were significant on a univariate level (PϽ.05) to identify the of Visual Acuity Loss of 3 or More LogMAR Lines combination of factors best related to the 3 outcomes. Kaplan- in Extrafoveolar vs Subfoveolar Nevus Using Kaplan-Meier Estimates Meier survival estimates were calculated on time to loss of 3 or more lines of logMAR visual acuity. Kaplan-Meier Estimates, % RESULTS Location of the Choroidal Nevus At2y At5y At10y At15y There were 3422 eyes of 3187 patients with choroidal Extrafoveolar (n=2207) Ͻ1 Ͻ11 2 nevus. The mean patient age at presentation was 60 years Subfoveolar (n=127) 7 15 20 26 All choroidal nevi (N=2334) Ͻ112 3 (median, 62 years; range, 4-97 years).
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