The patient was a 63-year-old man who complained of recently decreased central vision in the left eye. The visual acuity was 20/20 OD and 20/30 OS. He had been in good general health. The color picture on the right was taken 1 year prior to the color picture on the left. (We acknowledge Dr. Lou Mastrian in Hermitage, PA for the color photos.) After reviewing the images, what do you think is the most likely diagnosis? What treatment, if any, would you recommend?
This patient had a small choroidal melanoma. Features favoring this diagnosis include the marked growth in size, the subretinal fluid that is most readily seen on OCT, and the orange pigment that is due to lipofuscin accumulation and manifests with hyperautofluorescence. Regarding the OCT, note the elongated photoreceptors, which indicate that the neurosensory detachment is chronic. Photoreceptor elongation is less prominent near the fovea, where the detachment was presumably more recent. This accords with the history of a recent change in central vision. Regarding the autofluorescence study, the out-of-focus spots represent lipofuscin on the elevated tumor, and the punctate spots of nearby autofluorescence reflect stressed RPE related to the neurosensory detachment. B-scan ultrasonography shows a lesion with a 1.97 mm height. Posterior shadowing, which is often seen in melanomas, was absent in this patient due to the tumor’s small size.
Radioactive plaque treatment is planned. This treatment is very likely to cause substantial loss of central vision, and optic neuropathy is also possible. Prophylactic anti-VEGF treatment and grid laser treatment as needed can help prevent cystoid macular edema. However, the proximity of the tumor to the fovea will almost invariably result in radiation retinopathy and loss of photoreceptors.
This patient had a small choroidal melanoma. Features favoring this diagnosis include the marked growth in size, the subretinal fluid that is most readily seen on OCT, and the orange pigment that is due to lipofuscin accumulation and manifests with hyperautofluorescence. Regarding the OCT, note the elongated photoreceptors, which indicate that the neurosensory detachment is chronic. Photoreceptor elongation is less prominent near the fovea, where the detachment was presumably more recent. This accords with the history of a recent change in central vision. Regarding the autofluorescence study, the out-of-focus spots represent lipofuscin on the elevated tumor, and the punctate spots of nearby autofluorescence reflect stressed RPE related to the neurosensory detachment. B-scan ultrasonography shows a lesion with a 1.97 mm height. Posterior shadowing, which is often seen in melanomas, was absent in this patient due to the tumor’s small size.
Radioactive plaque treatment is planned. This treatment is very likely to cause substantial loss of central vision, and optic neuropathy is also possible. Prophylactic anti-VEGF treatment and grid laser treatment as needed can help prevent cystoid macular edema. However, the proximity of the tumor to the fovea will almost invariably result in radiation retinopathy and loss of photoreceptors.
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