Author: Saad Mahmud Khan (United Kingdom)
Co-authors: Evgenia Anikina
Diagnosing a choroidal melanoma can be challenging due to various factors including media opacities, small tumour dimensions or the clinician not having habitual familiarity with typical presentations. A missed diagnosis of a choroidal melanoma risks increased morbidity and mortality, especially when metastatic spread has occurred. Hence, early diagnosis and treatment is key in managing patients with this underlying malignancy. While choroidal melanoma is the commonest occurring primary intraocular malignancy, it is still uncommonly seen in clinical practice and so not as frequently dealt by ophthalmologists, especially those practising in non-specialist oncology centres. To increase awareness of how a choroidal melanoma may present, we discuss a patient case highlighting the diagnostic difficulties that may arise and how these could be overcome to avoid unnecessary interventions and delayed treatment for patients.
Patient care was provided jointly by the ophthalmology team at the Royal Berkshire Hospital and the specialist ocular oncology team at the Moorfields Eye Hospital
Verbal informed consent for patient information and images was obtained. The patient demographics and clinical details were obtained from the Medisoft (Medisoft Limited, United Kingdom) application. The patient images were obtained from the IMAGEnet (Topcon Corporation, Japan) data capturing system and the Moorfields hospital system.
A 72-year-old Caucasian female presented with a few months’ history of blurred vision in the left eye. On examination, visual acuity was 6/7.5 Snellen OD and 6/12 Snellen OS with normal intraocular pressures bilaterally. Fundoscopy was unremarkable and optical coherence tomography scanning displayed a small amount of central subretinal fluid in the left eye, as well as some retinal pigment epithelial changes. She was diagnosed with a sub-clinical choroidal neovascular membrane secondary to age-related macular degeneration and was scheduled to have regular clinic follow-ups. She presented eight months later with a marked reduction in visual acuity to hand movements with associated vitreous haemorrhage. A diagnosis of sub-retinal haemorrhage and haemorrhagic retinal detachment from a presumed eccentric choroidal neovascular membrane was made, which was managed with a pars plana vitrectomy. Intraoperatively, a subretinal dome-shaped swelling was noted, which appeared to be an organised haemorrhage. Following surgery, recurrent vitreous haemorrhage, and progression of early lens changes to more significant cataract precluded early visualisation of the fundus. When the haemorrhage failed to resolve promptly, ultrasonography was performed that revealed a pedunculated “collar stud” mass. The left eye was enucleated, and pathological analysis of the mass confirmed a malignant ciliary body and choroidal melanoma.
Accurate diagnosis of an underlying melanoma is vital to avoid unnecessary interventions and provide timely treatment. In the presence of media opacities, B-scan ultrasonography can be a useful diagnostic aid for visualising a lesion suggestive of a melanoma. For this to happen, the clinician must firstly hold a suspicion of an underlying tumour amid the other more common differentials. Secondly one must have access to expertise in ultrasound analysis as it can be challenging to diagnose a melanoma arising from the ciliary body, especially those that are in the early tumour stages with only basic ultrasonography skills. Choroidal melanoma presentation with vitreous haemorrhage is uncommon. Early suspicion can minimise the risk of vitrectomy in the setting of an underlying melanoma, with the consequent risk of tumour spread through surgical entry sites.
This research did not receive any funding. The authors declare no conflicts of interest.