Sir,
Retinal vasoproliferative tumour (VPT) is a benign entity known to be associated with epiretinal membrane (ERM) formation. The suspicion that some VPT-related membranes have vascular elements, based on clinical fundoscopic and flourescein findings is long-standing. For the first time, we present histological evidence of a vascularised ERM associated with VPT. This raises additional key questions about the aetiology of ERM and the pathogenesis of VPT.
Case report
A 34-year-old healthy post-partum female presented after a month of experiencing floaters and reduced vision in her left eye. Her unaided visual acuity was 6/4 OD and 6/24 OS.
Dilated fundoscopy of the left eye revealed a medium-sized vasoproliferative tumour (VPT), located in the inferotemporal periphery. Adjacent to the tumour were intra-retinal exudates and telangiectatic vessels, plus an overlying exudative retinal detachment (Figure 1a). The VPT was also associated with a vascular looking macular ERM. Fundus fluorescein angiography demonstrated late, generalised macular foveal capillary leakage.
(a) Fundus photograph of the vasoproliferative tumour. (b) H+E stain of the tumour-associated epiretinal membrane specimen at × 200 magnification. Further studies revealed that the tissue comprised mainly of a hyaline membrane with positive-immunostaining for both type IV collagen and G-FAP (laminocytes).
Initially, she was treated with transconjunctival cryotherapy under local anaesthetic as she was once again pregnant. Visual acuity continued to deteriorate as a result of the ERM. On delivery a vitrectomy, membrane peel and more comprehensive cryotherapy to the VPT was undertaken under general anaesthetic (GA). The ERM was sent for histological examination. Small capillary vessels resembling diabetic neovascular membrane were present, confirming that the ERM associated with this VPT was also vascular in nature (Figure 1b).
Comment
Vascular ERM is predominantly a finding in proliferative diabetic retinopathy (PDR).1, 2 In our Cambridge histopathological study of 207 ERMs, the only other non-PDR vascular ERM was induced by radiotherapy for basal cell carcinoma.3 In PDR, it appears that neovascularisation is a primary event, and glial tissue proliferation a secondary phenomenon.4
The aetiology of vascular ERM in VPT remains to be more clearly elucidated, raising further questions about the pathogenesis of both conditions. Apart from the vascular elements, the architecture and staining characteristics of this ERM was identical to non-vascularised ERM and posterior hyaloid membrane (PHM).5 It is more-than-likely that the interplay of tumour-derived cytokines have a pivotal role in deciding the angiogenic status of VPT associated ERMs.6, 7, 8
The lack of previous reports of associated vascular ERM may be because of underdiagnosis of the condition.
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Shankar, P., Bradshaw, S., Ang, A. et al. Vascularised epiretinal membrane associated with vasoproliferative tumour. Eye 21, 1003–1004 (2007). https://doi.org/10.1038/sj.eye.6702800
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DOI: https://doi.org/10.1038/sj.eye.6702800
