There is an orange lesion, and the overlying pigmented spots and surrounding hyperpigmentation suggest chronicity. B-scan ultrasonography does not show internal reflectivity or acoustic shadowing, but this could reflect the small size of the lesion. OCT shows an intact choriocapillaris with an outer mass that has some internal reflectivity.
The most likely diagnosis is choroidal hemangioma, because the orange coloration indicates a vascular lesion. Melanomas can have patchy orange pigmentation from lipofuscin, unlike the diffuse orange coloration of this lesion, and the surrounding hyperpigmentation would be atypical for a melanoma. Metastatic lesions tend to be yellowish and would also not typically include deep pigmentary changes. Indocyanine angiography can be very helpful in diagnosing hemangiomas, showing initial early hyperfluorescence and late wash-out phenomenon.
Choroidal hemangiomas can have overlying subretinal fluid, but such a small lesion is often asymptomatic. If the subretinal fluid interferes with or threatens vision, photodynamic therapy is generally efficacious.
Because of the remote possibility of a malignant process, we have been following this patient closely, and there has been no growth of the lesion.