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Purpose: To describe a complex case of choroidal osteoma complicated by choroidal neovascularisation and focal choroidal excavation and presence of pitchfork sign., Methods: A young female patient with confirmed diagnosis of choroidal osteoma was followed up for 5 years. Multimodal imaging including optical coherence tomography and fluorescein angiography (Spectralis HRA + OCT; Heidelberg Engineering, Heidelberg, Germany) was performed., Results: Optical coherence tomography showed the presence of a unilateral choroidal osteoma in the first visit which was later followed by the appearance of focal choroidal excavation. After 3 years, choroidal neovascularisation developed in choroidal osteoma area, with subretinal fluid, subretinal hyper-reflective material, hyper-reflective foci and pitchfork sign. Decalcification of the tumour was not noted in this patient. Treatment with one intravitreal injection of Aflibercept resulted in complete disappearance of subretinal fluid, subretinal hyper-reflective material, pitchfork sign and decreased hyper-reflective foci., Conclusion: Inflammatory response can be a propulsive element in the development of focal choroidal excavation and choroidal neovascularisation in choroidal osteoma patients.

A 33-year-old gentleman was presented with metamorphopsia in the left eye due to choroidal osteoma (CO) complicated by choroidal neovascular membrane (CNVM). Optical coherence tomography angiography (OCTA) proved to be a valuable, noninvasive tool in monitoring treatment response of CNVM. The tumor subsequently underwent decalcification over a period of 4 years. In addition, SS-OCT scans were instrumental in documenting the natural course of the tumor and focal choroidal excavations (FCE), which were found in correspondence with tumor decalcification. Close follow-up is warranted in FCE, secondary to decalcification of CO, as CNVM has been documented to occur on the slope or bottom of eyes with FCE., Competing Interests: None

An 11-year-old patient presented with blurred vision in both eyes resulting from bilateral choroidal osteoma. The patient was treated with a course of monthly intravitreal injections of ranibizumab for 3 months and this led to improvement of visual acuity. This effect was sustained without the need for further injections over a 2-year period of follow-up.

Heterotopic bone formation in the skin, osteoma cutis, occurs in a variety of clinical settings. Primary osteoma cutis arises in otherwise unaffected skin, often in patients with systemic conditions, whereas secondary osteoma cutis is associated with cutaneous neoplasms and inflammation (metaplastic ossification). Metaplastic ossification almost exclusively affects the dermis. Presented is a patient with posttraumatic bone formation in the subcutaneous fat, panniculitis ossificans traumatica, an entity that has only rarely been reported.

Choroidal osteoma is an unusual form of intraocular calcification seen in otherwise healthy eyes. It is a benign idiopathic osseous tumor of the choroid, typically seen in young females. Choroidal neovascular membrane (CNVM) is a complication seen in one-third of these patients and carries a poor visual outcome. We report a case of a 25-year-old hyperthyroid female with choroidal osteoma and subfoveal CNVM in her left eye which was successfully treated using low-fluence photodynamic therapy (PDT) with verteporfin followed by a single injection of intravitreal ranibizumab.

It is generally accepted that oxygen has a limited ability to diffuse into solid tumor masses. However, the question of the ability of chemotherapy agents to penetrate solid tumor masses has not been evaluated. This clearly would have an impact on the ability of chemotherapy to control microscopic disease during the "avascular" phase of growth. An attempt was made to evaluate the ability of methotrexate to penetrate solid tumor masses when grown in three dimensions (spheroids). Since methotrexate is used in the clinical management of human osteosarcoma, we chose this drug-tumor combination for our studies. This was done by growing human osteosarcoma cells into spheroids and exposing spheroids of various sizes to tritiated methotrexate. Audioradiographs were obtained from sections through the center of spheroids of various sizes. Our findings suggest that methotrexate has a limited ability to penetrate into avascular tumor masses when grown in three dimensions. This is most evident when the tumor masses are approximately 250 micron and larger in diameter. In addition, we compared the degree of penetration of methotrexate to the growth fraction of the tumor, as measured by tritiated thymidine, and found that the growth fraction was much greater than the fraction of cells reached by methotrexate. We conclude that the limited ability of methotrexate to penetrate solid tumor masses offers an alternative explanation for the limited effectiveness of methotrexate when used as an adjuvant for osteosarcoma. We question whether the established biochemical mechanisms for methotrexate resistance are comprehensive explanations for its limited clinical effectiveness.