Retinal sensitivity and photoreceptor arrangement changes secondary to congenital simple hamartoma of retinal pigment epithelium
The congenital simple hamartoma of the retinal pigment epithelium is a benign lesion and previous observations with noninvasive imaging have detected potential photoreceptor abnormalities and retinal function interplay.
A 35-year-old woman was found to have an asymptomatic, solitary, circumscribed, pigmented lesion in her left eye. The patient underwent ophthalmic examination including multimodal evaluation with fluorescein angiography, near-infrared reflectance scanning laser ophthalmoscopy, blue autofluorescence, enhanced-depth imaging spectralis B-scan optical coherence tomography (EDI-SBOCT), en face OCT angiography (OCT-A) and microperimetry plus adaptive optics imaging. Ophthalmoscopic examination revealed a juxtafoveolar pigmented lesion with feeding retinal arteriole, consistent with congenital simple hamartoma of RPE. There was no macular edema, exudation, hemorrhage, traction or subretinal fluid. Multimodal imaging of the mass using fluorescein angiography revealed intra-lesion late staining, near-infrared reflectance imaging demonstrated intrinsic hyperreflectivity, short-wavelength autofluorescence and red-free filter photography revealed blocked signal, and SBOCT showed abrupt shadowing. On OCT-A, an exclusive ring-shaped vascular circuit with increased foveal avascular zone was noted. Adaptive optics revealed cell density arrangement and retinal sensitivity correlations on microperimetry.
These findings suggest that this hamartomatous lesion might cause specific cellular changes that impact retinal sensitivity response and potentially result from vasculature malnourishment to the outer retinal layers.
KeywordsRPE Tumor Hamartoma Adaptive optics OCT-A Multimodal imaging
retinal pigment epithelium
enhanced-depth imaging spectralis B-scan optical coherence tomography
optical coherence tomography angiography
congenital simple hamartoma of the retinal pigment epithelium
internal limiting membrane
foveal avascular zone
inner plexiform layer
external limiting membrane
outer nuclear layer
vascular endothelial growth factor
Congenital simple hamartoma of the retinal pigment epithelium (CSHRPE) is a rare benign pigmented lesion. Few reports have been published in the literature and most authorities presume this to be a congenital disorder . This tumor is considered in the spectrum of RPE tumors based on clinical evaluation, and Gass et al. described the full thickness involvement and inner retinal surface permeation in an “umbrella” fashion [2, 3]. The largest case series has been reported by Shields et al.  and included clinical characteristics of five cases that demonstrated the presence of feeder vessel in 100% of cases . However, most reports have failed to demonstrate any histopathologic correlation as these tumors are often observed without surgical removal. Additionally, the functional impact of this tumor has not yet been explored.
Most current multimodal imaging techniques are insufficient for evaluation of CSHRPE partly due to the presence of heavy pigmentation within the mass. The SBOCT shadowing effect is a direct result of heavy pigmentation and has failed to demonstrate the internal structure of this tumor [4, 5]. Designing a new imaging strategy that could help address this unresolved question has been challenging.
Recently, Arjmand et al.  and Zola et al.  reported a case imaged with optical coherence tomography angiography (OCT-A) for noninvasive assessment of the intrinsic retinal microvasculature. Similar to them, we explored OCT-A of this mass and found better microvasculature detail than with fluorescein angiography (FA). However, in contrast to their reports, we noted a radial microvascular arrangement underneath the pigmented mass, rather than a microvascular tangle.
Herein, we assess CSHRPE with multimodal imaging to further evaluate retinal microvasculature, retinal sensitivity and photoreceptor arrangement.
Heidelberg HRA-multimodal assessment
Near-infrared reflectance imaging (Fig. 1c) demonstrated intrinsic hyperreflectivity, whereas short-wavelength autofluorescence (Fig. 1b) and red-free filter photography (Fig. 1d) revealed blocked signal by the lesion. Fluorescein angiography (FA) revealed mild ring-shaped fluorescence (Fig. 2g, red arrow) of the lesion in the arteriovenous phase that persisted without leakage into the late phase. Also, the FA showed early fluorescence (Fig. 2c) and late stained fluorescence (Fig. 2e) in the superior border lesion corresponding to the yellowish lesion. There was an outer retinal defect (Fig. 1g) on vertical section of EDI-SBOCT and of SBOCT (Figs. 1h, 5f on asterisk). Indocyanine green not revealed intralesional cyanescence, but only weak cyanescence on superior boundary (Fig. 2d–f). The mass appeared as a highly reflective lesion with deep shadowing by SBOCT (Fig. 1g, h). Interestingly rounded reflective vessels on SBOCT imaging (Fig. 1h, red arrow) was correlated to the Fig. 2g (red arrow). The feeder vessel was cross-sectioned by SBOCT scans on Fig. 2g1, g2 (red dashed line) in the inner retina layer.
En face and OCT angiography imaging
AO imaging and AO system analysis
Tumors of the RPE are uncommon. They are classified into diagnostic groups including CSHRPE, congenital hypertrophy of the RPE, combined hamartoma of the retina and RPE, congenital albinotic and amelanotic spots of the RPE, torpedo maculopathy, and congenital RPE dysgenesis . It has been theorized to be a congenital proliferation of RPE cells with benign cytological features that aberrantly migrated to involve all layers of the neurosensory retina [2, 3]. Accordingly, b-scan OCT images from the present study demonstrate deep architectural modifications under the pigmented part of the lesion (Figs. 1G, 4E).
In agreement to Gass  description of intrinsic vasculature as an element to characterize CSHRPE, the present report also demonstrated an exclusive vascular circuit distinguishing from other OCTA reports [6, 7], as well as an evident patent feeder vessel (Figs. 2, 3) as published by Shields and colleagues  in 100% of their cases.
According to the literature, surrounding mild retinal traction can be associated to CSHRPE in 80% cases . In one surgical case, vitreomacular traction (VMT) and secondary retinal thickening associated with CSHRPE lead to surgical repair and postoperative histopathological specimen analysis demonstrated a nodular proliferation of hyperplastic RPE cells with attached gliotic retina and ILM, similar to current histological studies from VMT and epiretinal membrane (ERM) surgeries [11, 12]. This case  involved an elderly patient with important vitreo-macular traction dragging the inner retina into a pre-retinal macular fibrosis formation. Subsequently, predictable large presence of fibroblastic tissue and less significant angiomatous component was confirmed on small specimen samples. The postoperative OCT after retinal surgical revealed only partial-thickness retinal defect with preservation of outer nuclear layer (ONL), including discontinuous ellipsoid band and RPE atrophy. Differently, our case reported herein demonstrated no VMT, but also showed partial-thickness retina involvement as mentioned above.
For the first time in the literature according to a Medline search, the present report confirms the presence of cones inner/outer segments in a CSHRPE using adaptive optics analysis (Fig. 6D-orange dashed square and Fig. 6G1, cone cell density). In this regard, two representative juxta-foveolar retina images were matched for comparison (Fig. 6C-green dashed square and Fig. 6D-blue dashed square). On the lesion area, there was a center portion with a very good cell density around 16.000 cells (normal range 20.000–30.000) surrounded by a region of complete absence of cones that corresponded to areas of retina and RPE atrophy. Despite below the normal range values, the island of good cell density on the hamartoma region had higher density than the matched unaffected retina. As expected, inward to two (2°) centered degree the juxta-foveolar unaffected areas from both eyes showed reduced cone-cells detection (Fig. 6E1, F1); not obligatory meaning photoreceptor cell death but reduced regular capability of software cell detection due to excessive packing of cones inner/outer segments in this 2° region . In other words, our report shows that there are cones in good density on an CSHRPE, and maybe the unpacking effect of the lesion on photoreceptors architecture may facilitate cone inner/outer segments detection, leading to higher values of cell density when compared to normal unaffected retina.
In an effort to explore the potential retinal function at the site of this pigmented lesion and surrounding margin, we used microperimetry to determinate the sensitivity response (Fig. 5a, b). The OS-sensitivity map detected regular sensitivity response over the pigmented tumor as corroborated by the photoreceptor density findings using AO. Compared to the OD, the OS-sensitivity map detected a focal reduced retinal sensitivity among corresponding areas (yellow and red asterisks) of yellowish RPE atrophy (Fig. 5d1) presented as transmission FA-hyperfluorescence (Fig. 5d2), In this area, there is also SBOCT-ellipsoid and outer segment hyper reflective layers defects (Fig. 5f, black asterisk) and reduced photoreceptor density on AO analysis (Fig. 5e). In fact, external retinal layer disruption has been reported  and Hypothetical explanations include RPE rearrangement and anomalous inner retinal allocation sustained by feeder vessel nourishment.
Strengths of this study include the systematic qualitative multiple correlated imaging assessment from advanced technology using multimodal devices to better understand the architectural changes of CSHRPE. Limitations of this study include the ones usually related to the case report nature of the manuscript. Small number with limited variability of data. Limitations of the imaging techniques such as cone density measurements as commented above.
In summary, OCT-A, adaptive optics, and microperimetry findings provide novel data that could predict functional visual outcome of this tumor. Future research multimodal imaging of this rare condition is warranted to better understand the pathophysiology and visual impact of this condition.
MWR is the primary contributor to research design. DBC, MWR, and CD are responsible for research execution and data acquisition. RJ, CLS are the primary contributors to data analysis and interpretation. Manuscript preparation by MWR, DBC, and CD with revisions provided by RJ, and CLS. All authors read and approved the final manuscript.
We thank Ms. Lucélia Albieri (ophthalmic technician) from University of São Paulo (Brazil) for image acquisition and thank to Mr. Mike Pirunski (Librarian) from Wilmer Eye Institute (Johns Hopkins University, Baltimore-USA) for provide all the papers citation on references.
The authors declare that they have no competing interests.
Availability of data and materials
Murilo W. Rodrigues, M.D., had full access to all of data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
We have not sent this case report to the Ethics Committee Institution, as the patient was attempt in the public healthcare in a small city and we agreed that it was a simple case report and not invasive and intervention procedure was performed. All the comprehensive ophthalmologic evaluation had performed in the routine ambulatory safely. The patient complied the inform consent signed solely.
Role of the sponsors
Sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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- 5.Baskaran P, Shukla D, Shah P. Optical coherence tomography and fundus autofluorescence findings in presumed congenital simple retinal pigment epithelium hamartoma. GMS Ophthalmol Cases. 2017;25:7.Google Scholar
- 6.Arjmand P, Elimimian EB, Say EAT, shields CL. Optical coherence tomography angiography of congenital simple hamartoma of the retinal pigment epithelium. Retin Cases Brief Rep. 2017;1–4.Google Scholar
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