Laser Indirect Ophthalmoscopy-Guided Transpupillary Thermotherapy Versus I-125 Plaque Brachytherapy for Choroidal Hemangioma

<b>Background:</b> Choroidal hemangioma, a rare benign vascular tumor, can cause visual loss due to subretinal fluid. Photodynamic therapy (PDT) with verteporfin has been the standard treatment, with plaque brachytherapy reserved for PDT failure. Verteporfin is unavailable in many regions in the Middle East, including Jordan, leaving plaque as the main alternative; however, plaque often leads to poor visual outcomes despite tumor control. To improve visual outcomes, we introduced transpupillary thermotherapy (TTT) via laser indirect ophthalmoscopy (LIO) as a practical, widely available, vision-preserving treatment. <b>Methods:</b> We retrospectively reviewed 13 patients with choroidal hemangioma treated at King Hussein Cancer Center. Patients received either plaque brachytherapy or LIO-guided TTT. Clinical data included visual acuity at baseline, tumor thickness reduction, subretinal fluid status, and visual outcome. <b>Results:</b> All patients had unilateral circumscribed choroidal hemangioma, and 10 (77%) were males. At diagnosis, the visual acuity was ≤0.5 in all patients (100%) and <0.1 in six (46%) patients. Seven patients (54%) received LIO-guided TTT and six (46%) underwent I-125 plaque brachytherapy. Tumor thickness was 3.0-5.0 mm in 12 (92%) cases; the median thickness in the I-125 plaque brachytherapy group was 4.5 mm (range, 4.5-5.0 mm), whereas in the LIO-guided TTT group it was 3.8 mm (range, 2.9-5.0 mm). At a median follow-up of 20 months (mean 24, range 12-48 months), five out of seven patients (71%) treated with TTT showed significant visual improvement, while the remaining two (29%) had stable vision; none experienced deterioration. In contrast, none of the six plaque-treated patients (0%) demonstrated any improvement in visual acuity; four remained stable and two worsened. This difference was statistically significant (<i>p</i> = 0.021). Tumor thickness was reduced in both groups, with a median reduction of -56% in the plaque group and -36% in the TTT group. All patients achieved complete resolution of subretinal fluid. <b>Conclusions:</b> LIO-guided TTT is an effective vision-preserving treatment for choroidal hemangioma. While both modalities-controlled tumor growth, only TTT resulted in significant visual improvement. This study demonstrates that LIO-guided TTT can replace plaque brachytherapy in regions where verteporfin (PDT) is unavailable, offering an accessible, practical, and superior alternative for preserving vision in patients with choroidal hemangioma.