A middle aged female with floaters in her left eye...
A middle aged female presents with sudden onset of left eye pain, worsening vision, and floaters in the periphery of her vision. She has an associated headache. Her vision has been gradually decreasing prior to the onset of pain. You place the ultrasound on her eye and see this:
What's your differential? How would you work this up?
Scroll down for the Case Conclusion.
Final Diagnosis: Choroidal Melanoma
Case Conclusion: This patient had a known diagnosis of choroidal melanoma, and was actively being treated with radiation. There was concern for acute angle closure glaucoma, however IOP pressures were normal on ophthalmology exam. She was treated for a migraine and continues to follow up in ophthalmology clinic.
Learning Points: Though it is rare, Choroidal melanoma is the most common primary malignant intraocular tumor with an incidence of 6 cases per 1 million people in the United States. The incident is higher in Caucasians, especially those of Northern European countries. Mostly commonly it is found in patients over 50 years old with a male predominance, however, there is a slight female predominance in those case 18-50 years old.
The melanoma arises from melanocytes in the choroid, the highly vascular tissue layer beneath the retina. The size of the tumor varies with the base measuring 2mm to 24 mm in diameter. As the tumor grows it takes on a mushroom or dome shape and can develop different lobes.
Image source: http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v6/v6c070.html
Patients typically present with blurred vision, floaters, ocular pain, and progressive visual fleld loss. If the tumor originates further away from the macula, the patient will present later in the course of disease, as they will be asymptomatic for longer. The differential includes choroidal hemangiomas, foreign body, localized choroidal detachment, hemorrhagic retinal detachment, and retinalglioma. The ultrasound will show a mushroom like tumor with vascularization. Patients typically have further imaging in the form of CT or MRI to determine extraocular extension.
These patients will often have metastatic disease at the time of their presentation, with the most common sites of metastasis being liver (90%), lung (24%), and bone (16%). Your evaluation should include liver enzymes and a chest x-ray for evaluation of metastases. Treatment for these patients varies from enucleation, radioactive plaque therapy, external radiation, and local resection. The prognosis at 10 years from diagnosis and treatment is a mortality rate of 30-50%, typically to due metastatic disease. One year survival for patients with liver metastases is a mere 20%.
Case conclusion by Alicia Oberle
References:
1. Garcia-Valenzuela E, Roy H, et al. Choroidal Melanoma. Medscape. Updated 9/15/15. Accessed 3/12/16.
2. Singh P, Singh A. Choroidal Melanoma. Oman Journal of Opthalmology. 2012 Jan-Apr; 5(1): 3-9.