CASE

A 57 year old female with a past medical history significant for hypercalcemia status post parathyroidectomy, chronic kidney disease, and hypothyroidism presented to the Emergency Department with 3 days of floaters and “lightning bolt” white flashes in the temporal field of her right eye in the absence of eye trauma. She also reported right periorbital pain. She did not have blurry vision, diplopia, loss of vision, scalp tenderness, jaw claudication, fevers, chills, or weight loss. She denied photophobia despite wearing sunglasses in the Emergency Department.  Her mother had died from choroidal melanoma, but the patient had not seen an ophthalmologist in 15 years.

Her uncorrected visual acuities were 20/60 OD and 20/40 OS. Intraocular pressure, pupillary reaction, and extraocular movements were normal. Point of care ultrasound (POCUS) revealed three hyperechoic, solid lesions with posterior acoustic shadowing in her right eye.

DIAGNOSIS

Subclinical posterior vitreous detachment with incidental sclerochoroidal calcification.

DISCUSSION 

Sclerochoroidal calcification is a rare ocular condition that involves deposition of calcium in the sclera and choroid. It is found mostly in Caucasian patients over 50 years old. [1, 2] It is typically asymptomatic and found incidentally on routine exam. These lesions can be unilateral or bilateral, unifocal or multifocal, and are most commonly located in the superotemporal fundus. Complications are rare, but include retinal detachment and development of a choroidal neovascular membrane which can cause visual defects and vision loss. [3]

Sclerochoroidal calcification is usually idiopathic however, a case series found it to be associated with hyperparathyroidism (27%), parathyroid adenoma (15%), Gitelman syndrome (11%), and Bartter syndrome (2%). As such, patients newly diagnosed with these lesions should undergo a full work up for these syndromes. [4]

Case Resolution

In our patient’s case, an ophthalmology consultation was obtained. Her symptoms of floaters and flashers were attributed to a subclinical posterior vitreous detachment that ophthalmology thought was too small to be detected on ultrasound. The lesion in the back of the eye was diagnosed as an incidental finding of sclerochoroidal calcification secondary to systemic hypercalcemia versus neoplasm given her family history. She was scheduled for follow-up in the retina clinic but she was not compliant with her appointment.

TAKE-AWAYS

• Sclerochoroidal calcifications are hyperechoic lesions with a posterior acoustic shadow most frequently located in the superotemporal fundus.

• They are typically benign and do not typically cause visual deficits.

• Patients with newly diagnosed sclerochoroidal calcifications should have parathyroid hormone, calcium, and vitamin D levels measured to evaluate for underlying disorders.

AUTHOR: Courtney Pedersen, MD, MPH is a PGY-2 in Emergency Medicine at the Warren Alpert Medical School of Brown University.

FACULTY REVIEWER: Kristin Dwyer, MD is Ultrasound Faculty at Emergency Medicine at the Warren Alpert Medical School of Brown University

REFERENCES

1. Shields, Jerry A., and Carol L. Shields. "CME review: sclerochoroidal calcification: the 2001 Harold Gifford Lecture." Retina 22.3 (2002): 251-261.

2. Honavar, Santosh G., et al. "Sclerochoroidal calcification: clinical manifestations and systemic associations." Archives of Ophthalmology 119.6 (2001): 833-840.

3. Cooke, C. A., C. McAvoy, and R. Best. "Idiopathic sclerochoroidal calcification." British journal of ophthalmology87.2 (2003): 245-246.

4. Shields, Carol L., et al. "Sclerochoroidal calcification: clinical features, outcomes, and relationship with hypercalcemia and parathyroid adenoma in 179 eyes." Retina 35.3 (2015): 547-554.