a 48-year - old woman with no remarkable medical history presented with decreased visual acuity and metamorphopsia in her right eye , which had gradually progressed over several months . her best - corrected visual acuity ( bcva ) , measured on a snellen chart , was 0.5 , and her intraocular pressure , as determined on the goldmann applanation tonometer ( haag streit , bern , switzerland ) , was 14 mmhg . an examination of the fundus showed a well - defined , 4.9 by 5.2 mm , whitish - yellow and slightly elevated lesion in the posterior pole ( fig . fluorescein angiography and optical coherence tomography ( oct ) showed retinal pigment epithelial degeneration , macular edema and subretinal hemorrhage , suggesting choroidal neovascularization ( cnv ) ( fig . treatment was recommended using a combination of pdt with verteporfin and intravitreal bevacizumab ( avastin ) injections at 5-day intervals . two weeks later , the fluorescein angiography showed that the subretinal hemorrhage and leaking of the fluorescein dye had decreased and her metamorphopsia had improved . four weeks after starting treatment , her bcva had improved to 0.8 , and to 1.0 after 12 weeks . choroidal osteoma is a rare ossified tumor , first described in 1978 , found predominantly in healthy young women , and appears in a unilateral position in most patients . at presentation , subretinal fluid , hemorrhage and alterations in photoreceptors associated with cnv can reduce visual acuity , but the mechanism of cnv is unknown . treatments include pdt , intravitreal bevacizumab ( avastin ) or ranibizumab ( lucentis ; genentech inc . , south san francisco , ca , usa ) , laser photocoagulation and thermotherapy . these treatments are designed to conserve the fovea by decalcifying the osteoma , ultimately resulting in suppression of cnv . pdt was found to cause the regression of a subfoveal choroidal osteoma accompanied by cnv . the beneficial effects of pdt include not only improvements in visual acuity and metamorphopsia , but a reduction in the size of the cnv , as shown by oct , and a reduction in leakage during late stage fluorescein angiography [ 4 - 6 ] . in contrast , intravitreal injection of an anti - vascular endothelial growth factor ( vegf ) antibody was reported to be superior to pdt , and the latter was associated with poor visual outcome and the possible need for multiple re - treatments [ 7 - 9 ] . in patients with cnv due to age - related macular degeneration , treatment combinations of pdt and intravitreal anti - vegf injection have been tried . although these combination therapies have not proven to be superior to using either agent alone , it reduces the risk of multiple pdt , which may induce cnv recurrence by aggravating choroidal ischemia and subsequent over - expression of vegf . in addition , rishi et al .   reported that combination therapy with pdt and intravitreal bevacizunmab appeared to be effective in the treatment of cnv secondary to toxoplasma retinochoroiditis . therefore , we utilized a combination of pdt with verteporfin and intravitreal bevacizumab ( avastin ) with our 48-year - old female patient who had presented with decreased visual acuity in her right eye due to cnv secondary to choroidal osteoma . two weeks later , we found that the subretinal hemorrhage had decreased due to the suppression of cnv . her bcva improved to 0.8 at 4 weeks and to 1.0 at 16 weeks , and there were no complications throughout the 16 week follow - up period . these results indicate that the combination of pdt with verteporfin and intravitreal anti - vegf injection could have a synergistic effect that could reduce the need for repeated injections in the treatment of choroidal osteoma with cnv , especially in cases of large sized , and those non - responsive to anti - vegf injections or pdt alone . larger studies with longer follow - up may reveal that the visual outcome with combination therapy could be better than pdt or anti - vegf alone .
choroidal osteoma is a benign ossified tumor that is found predominantly in healthy young women during their second and third decades of life . 
 the lesions are white - to - cream or orange in color , are located in the peripapillary and macular areas , and are unilateral in most patients . 
 the symptoms of choroidal osteoma include decreased visual acuity and metamorphopsia or scotoma corresponding to the location of the osteoma , but some patients have no symptoms . 
 prognosis of vision varies according to tumor location , retinal pigment epithelial and sensory retinal degeneration , subretinal fluid and hemorrhage , and development of a subretinal neovascular membrane .