alexa Sclerochoroidal Calcification: Parathyroid Connection | OMICS International
ISSN: 2472-4971
Journal of Medical & Surgical Pathology
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Sclerochoroidal Calcification: Parathyroid Connection

Subhashini Yaturu1,2*, Satya Potluri1,2, Van Alstine1,3 and Anthony W1

1Dorn VAMC, Columbia, South Carolina

2School of Medicine, University of South Carolina, Columbia, South Carolina

3Indiana University School of Optometry, Bloomington, Indiana

*Corresponding Author:
Subhashini Yaturu
Section of Endocrinology and Metabolism, School of Medicine
University of South Carolina, Columbia, South Carolina
Tel: 803-776-4000-6092
E-mail: [email protected]/[email protected]

Received date: July 12, 2017; Accepted date: July 24, 2017; Published date: July 30, 2017

Citation: Yaturu S, Potluri S, Alstine V, Anthony W (2017) Sclerochoroidal Calcification: Parathyroid Connection. J Med Surg Pathol 2:148. doi: 10.4172/2472-4971.1000148

Copyright: © 2017 Yaturu S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Medical & Surgical Pathology

Abstract

Objective: Sclerochoroidal calcification is a benign condition often noted incidentally on ophthalmoscopic examination of the fundus. It may be associated with metabolic disorders such as hyperparathyroidism, Gitelman syndrome, pseudo hypoparathyroidism. Here we present a case of asymptomatic Sclerochoroidal calcification incidentally found on a routine fundoscopic examination of a patient with diabetes and primary hyperparathyroidism. Methods: The following is a case report with a review of the literature. Results: 62 year old Caucasian male was referred to Endocrine section from ophthalmology for work up of possible secondary causes of an incidental finding of sclerochoroidal calcification noted on routine exam for diabetic retinopathy in 2015. The lesion was present in prior fundus photos from 2011 with no significant changes, indicating stability of the lesion over the last 4 years. Ophthalmic exam noted all normal findings for pupillary reaction, extraocular motility, intra ocular pressures, visual fields and acuity of vision was 20/20 in both eyes and there was no evidence of diabetic retinopathy on dilated fundus exam. An incidental finding of an elevated round yellow lesion superior to the optic nerve head was noted on the fundus exam in the left eye behind the lesion consistent with dense intra-lesional calcification. The lesion did not demonstrate any abnormal vasculature, pigmentation, or retinal fluid. Ophthalmic ultrasonography testing revealed hyper-reflectivity with acoustic shadowing. On work up found to have primary hyperparathyroidism. Whether they are related or incidental problems together is not clear. Conclusion: Though Sclerochoroidal calcification can be idiopathic in most cases, clinicians are advised to rule out metabolic disorders such as abnormal calcium and phosphorous metabolism.

Keywords

Sclerochoroidal calcification; Primary hyperparathyroidism; Vitamin D deficiency

Introduction

Sclerochoroidal Calcification (SCC) is a benign ocular condition often noted incidentally on ophthalmoscopic examination of the fundus. It is characterized by yellow-white irregular sub retinal lesions, usually in the superotemporal mid-periphery of the fundus. It can clinically simulate a number of intraocular tumors like choroidal metastasis, choroidal melanoma, choroidal osteoma and melanoma. Most cases are idiopathic (79%) and 21% of cases can be associated with hyperparathyroidism, parathyroid adenoma, Gitelman syndrome, Bartter syndrome, chronic renal disease, and metabolic imbalance after diuretic use; case reports in association with Vitamin D deficiency and Al Bright’s syndrome. The idiopathic form appears to be seen mainly in older patients and hence some consider it as an age-related change. Screening for associated conditions were recommended to be carried out to exclude an underlying systemic disorder such as pseudo hypoparathyroidism.

The frequency of the various systemic associations with sclerochoroidal calcification was mostly reported in two reviews and case reports [1,2]. Here we report a case of asymptomatic Sclerochoroidal calcification incidentally found on a routine fundoscopic examination of a patient with diabetes and primary hyperparathyroidism.

Case Details

A 62 year old Caucasian male was referred from ophthalmology clinic to Endocrine section for work up of possible secondary causes of an incidental finding of sclerochoroidal calcification (Figure 1).

medical-surgical-pathology-Fundus-photo

Figure 1: Fundus photo showing sclerochoroidal calcification.

Per ophthalmic note, the patient was presented for a routine diabetic ocular examination. The medical history is notable for type 2 diabetes since 2006, left nephrectomy for renal cell carcinoma, CAD, COPD, hypertension, hypothyroidism since childhood, and CKD stage 3. Patient was not on calcium or Vitamin D supplements, but was on low dose HCTZ. Patient had no systemic or visual complaints. Review of the medical record did reveal elevated calcium of 10.3 mg/dL with no simultaneous PTH, 9 months prior to Endocrine clinic visit. The lesion was present in prior fundus photos from 2011. Calcium levels then were in normal range in 2011.

Clinical exam was unremarkable with no additional significant findings. Laboratory work up revealed normal calcium and phosphorus levels with PTH intact of 124.9 pg/mL (Ref Range: 29.1 to 79.9), PTH intact was 115 pg/ mL one month prior to the Endocrine visit, and eGFR of 47mL/min with serum creatinine of 1.6. Additionally, 25 (OH) vitamin D levels were 26.9 ng /mL with 24 hour urine calcium of <140 mg/d. With a clinical diagnosis of Primary hyperparathyroidism, had a parathyroid scan. Parathyroid scan revealed a positive uptake in the inferior aspect of the right thyroid gland suggestive of parathyroid adenoma (Figure 2). DXA scan revealed a normal bone mineral density.

medical-surgical-pathology-Optical-coherence

Figure 2: Optical coherence tomography.

Ophthalmic exam noted all normal findings for pupillary reaction, extraocular motility, intra ocular pressures, and visual fields by confrontation test and best corrected vision was 20/20 in both eyes. There was no evidence of diabetic retinopathy on dilated fundus exam. An incidental finding of an elevated round yellow lesion superior to the optic nerve head was noted on the fundus exam in the left eye.

The lesion did not demonstrate any abnormal vasculature, pigmentation, or retinal fluid. The lesion was present in prior fundus photos from 2011 with no significant changes, indicating stability of the lesion over the last 4 years. Ophthalmic ultrasonography testing revealed hyper-reflectivity with acoustic shadowing behind the lesion consistent with dense intra- lesional calcification (Figure 3).

medical-surgical-pathology-Ophthalmic-ultrasound

Figure 3: Ophthalmic ultrasound.

Spectral Domain Optical Coherence Tomography (SD-OCT) revealed marked sclerochoroidal elevation at the site of the lesion with absence of retinal fluid or neovascularization, normal pigment epithelium and neurosensory retina and intact overlying the lesion (Figure 4).

medical-surgical-pathology-Sestamibi-parathyroid

Figure 4: Sestamibi parathyroid scan showing persistant increased uptake in thyroid gland at 2 hr delayed images.

Discussion

The interesting points in the patient presented include that he had sclerochoroidal calcification at least 3 years prior to mild hypercalcemia; remained asymptomatic over 4 years; though patient had mild hyperparathyroidism biochemically, parathyroid scan did reveal parathyroid adenoma, confirming primary Hyperparathyroidism. The most common systemic condition with association to SCC seems to be hyperparathyroidism, Gitelman syndrome and pseudohypoparathyroidism

Since it is an uncommon condition, it is worth reviewing the literature. The biggest case series published include 118 patients and among them 53 subjects had metabolic work up. Among those 53, only 33 had PTH levels available. Among these 33 subjects, 9 subjects (27%) had abnormal PTH levels and the adenoma identified in 5 subjects (15%). Other associations include Gitelman’s syndrome (6/53, about 11%) and Barter’s syndrome [3]. The longest follow up seems to be in that series was 4 years mean follow up. In about 79% of cases, no secondary cause was found. Other conditions reported in case reports include Albright's hereditary osteodystrophy and vitamin D deficiency [4].

Characteristic findings are irregular yellow-white sub retinal lesions, mostly located around 9.00 to 3.00 clock position of the fundus. It can clinically simulate a number of intraocular tumors like choroidal metastasis, choroidal melanoma, choroidal osteoma and melanoma. Confirmation with ultrasonography or computed tomography establishes that this lesion is calcified. The lesions could be unilateral or bilateral. It is usually asymptomatic as the vision is not involved. At mean 4 years follow up, it was reported that there was no enlargement of the lesion, decalcification, or related sub retinal fluid/hemorrhage, choroidal neovascularization, or vision loss [5]. Visual prognosis seems to be good, as the lesions are typically located away from the macula and foveal encroachment is rare [6].

Based on enhanced depth optical coherence tomography sclerochoroidal calcification was described as a scleral-based disease and could be classified based on four "mountain-like" topographic patterns. They include flat (Type 1) (n=9) at median thickness of 1.2 mm, rolling (Type 2) (n=28) at 1.4 mm thickness, rocky-rolling (Type 3) (n=21) at 2.1 mm thickness and table mountain (Type 4) (n=9) at a thickness of 1.9 mm [5,7]. Rarely sight-threatening complications that have been reported with sclerochoroidal calcification include choroidal neo-vascularization and serous detachments. The electroretinogram abnormality suggests a retinopathy involving mostly rods which may be due to the involvement of the G proteins involved in normal photoreceptor functioning. The pathogenesis of sclerochoroidal calcification is not entirely clear.

Wong and associates first described histopathologic findings of sclerochoroidal calcification in postmortem eyes of a patient with pseudo hypoparathyroidism. It was reported that the earliest calcification occurs in the sclera.

Conclusion

SCC is an incidental finding and the diagnosis is usually made by recognition of the clinical features of this lesion on ophthalmoscopy, and confirmation with ultrasonography or computed tomography to establish that this lesion is calcified. Most often SCC can be idiopathic in most cases, metabolic evaluation and clinical examination is important to exclude associated systemic conditions. It is possible that our patient had both sclerochoroidal calcification independent of hyperparathyroidism since our patient had the eye features ahead of hypercalcemia.

Statement of Ethics

A case report at this institute does not require IRB approval as long as data is presented in an anonymous manner in which participants were not identifiable as in this case report.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Recommended Conferences

Article Usage

  • Total views: 231
  • [From(publication date):
    August-2017 - Dec 14, 2017]
  • Breakdown by view type
  • HTML page views : 200
  • PDF downloads : 31
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version