Choroidal melanoma: different forms of presentation

     Purpose: Choroidal melanoma is the most common primary intraocular malignancy in adults. This tumor is often asymptomatic until some complication arises, such as retinal detachment, affecting central vision. By this time the visual prognosis is poor. The purpose of this poster is to describe 4 cases of choroidal melanoma with different therapeutic approaches (proton beam radiotherapy and enucleation).

     Setting: Ophthalmology Department, Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal. Methods: Description of four patients with choroidal melanoma with distinct clinical presentation. Patient workup included retina photographs, ocular B-scan ultrasonography and magnetic resonance imaging (MRI) of the orbits. Systemic evaluation included liver enzymes and abdominal ultrasound.

     Results: Four patients were diagnosed with choroidal melanoma. Patient number 1 was asymptomatic and was diagnosed by fundoscopy in a routine evaluation. Patient number 2 came to the emergency room complaining of a superior defect in the visual field and was diagnosed an exsudative inferior retinal detachment associated to a pigmented tumor. Patient number 3 came to observation because of decreased visual acuity and was diagnosed a retinal detachment involving the posterior pole. Fundoscopic evaluation documented also a non pigmented tumor and ultrasound and MRI didn’t manage to clear the diagnosis. Patient number 4 came to the emergency room with ocular pain in the context of acute glaucoma associated with a volumous intraocular tumor. Patients 1 and 2, whose tumors were less than 6 mm thick in ocular ultrasound, were submitted to proton beam radiotherapy in Switzerland.  The other two were enucleated and histopathology confirmed the diagnosis of choroidal melanoma. Patient number 1 kept good visual acuity and the patient number 2 kept some central vision despite maintaining variable subretinal fluid. Systemic workup was negative in all patients. The authors present the retina, ultrasound and MR images documenting these cases and histopathologic images as well.

     Conclusions: Until about 1970, enucleation was the standard treatment to choroidal melanoma. In the early 1970s, radiotherapy and other treatment approaches, with the goal of preserving the eye, became increasingly popular. External beam irradiation using charged particles, such as protons, may conserve a useful level of vision, depending on the size of the tumor, its location with respect to the optic disc and macula and associated complications, namely retinal detachment and glaucoma. It is important to notice that in the first patient the diagnosis was made in a routine fundoscopic evaluation, so the early diagnosis is possible and warrants a better vital and visual prognosis.