Acquired retinal astrocytoma: Transpupillary thermotherapy may be a viable alternative treatment option

A 14-year-old boy was referred with complaints of diminution of vision in the right eye for the past 1 year. He had no known systemic illness or family history of genetic disorders. His best-corrected visual acuity (BCVA) in the right eye was 20/200, N36 while the left eye was 20/20, N6. The anterior segment was unremarkable. The right eye fundus examination revealed an amelanotic juxta-papillary mass with surrounding exudation [Fig. 1a]. Aided by SS-OCT [Fig. 1b] and FFA [Fig. 2] findings a diagnosis of presumed acquired retinal astrocytoma (ARA) was made and the lesion was treated with photodynamic therapy. Minimal reduction in exudation without alteration in the lesion size was noted at 6-month follow-up. As an alternative to standard therapy, transpupillary thermotherapy (TTT) was done for the patient. A 100 mW power, for 3 minutes was applied, with 3 mm spot size, delivering 17 mJ of total energy. A significant reduction in the lesion size with a resolution of hard exudates at the macula and one-line improvement in visual acuity on the early treatment diabetic retinopathy study (ETDRS) chart was noted 2 months after TTT [Figs. 3 and 4].Figure 1: Fundus picture showing a juxtapapillary yellow-white mass lesion 4.5 × 6 mm in size with surrounding intra and subretinal exudation (a). Optical coherence tomography picture showing presence of a hyperreflective non calcified mass lesion arising from inner retinal layers with back shadowing (b)Figure 2: Fluorescein angiography image showing the presence of fine branching vascularity of the mass with minimal hyper fluorescence in the early phase (a), the fluorescence increases through transit with profuse leakage in the late phase (b)Figure 3: Image showing the tumor response to the course of treatment. Fundus picture showing the appearance of the tumor at presentation (a). 6 months post Photodynamic therapy fundus image showing minimal reduction of exudates over macula without any significant reduction in tumor size, with presence of preretinal haemorrhage (b). 2 month after Transpupillary thermotherapy fundus image showing a significant reduction in size of mass lesion with near-complete resolution of exudation over macula and papillomacular bundle (c)Figure 4: Comparison Optical coherence tomography images showing the tumor height 6 months after photodynamic therapy (a) and a significant reduction in its size after 2 months of transpupillary thermotherapy (b)Discussion ARA is a benign intraocular glial tumor, having no association with tuberous sclerosis.[1] It is typically juxta-papillary or macular in location.[2] Unlike retinal astrocytic hamartoma (RAH), it lacks calcification and exhibits progressive growth.[12] Current treatment modalities for ARA include photodynamic therapy (PDT), laser photocoagulation, and plaque radiotherapy. Mennel et al. and Shields et al., first described the use of PDT for RAH and ARA, respectively.[34] Effectiveness of TTT to our knowledge has not been described in cases of ARA. We believe TTT has a dual mode of action. First, it causes thermal cytotoxic damage leading to cell apoptosis. Second, it causes heat-induced sclerosis of the vascular channels causing tumor regression and resolution of exudation.[5] This photo essay highlights the typical findings in a case of ARA and also reports a yet undescribed treatment modality in such cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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