Ocular Melanoma Case Study

Ocular Melanoma Case Study

History

Patient: Mr.X a 60 Year old Male Accountant

Reason for Visit: Finding that vision in his LE has become significantly blurry in the last two weeks.

GH: Nil. Last GP visit one year ago.

POH: Nil. Last Eye examination: unknown

FOH: Nil.

 

Clinical Assessment


Pretest

Ocular Motility: Full

Pupils. PERRLA DCN

Cover Test: Orthophoric

Confrontation: R. Full L. Nasal Hemianopia

Red Cap Test: R. 10/10 L. 7/10

Acuity

VA Unaided: R. 6/9 L. 6/12 (eccentric fixation)

Refraction: R. plano/-0.75 x 105 = 6/6   L. Unable to refract

Slit Lamp Examination
Anterior Segment: Normal OU
Posterior Segment: LE. Large temporal mass

Differential Diagnosis


Retinal detachment or tears

Posterior vitreous detachment

Branch Retinal Vein/Artery Occlusion

Optic Nerve compression

Uveal Melanoma

Management

Urgent referral to the Royal Victorian Eye and Ear Hospital for them to initiate assessment and systemic work up for metastasis. 
 

Discussion

Uveal melanoma is a serious, life threatening intraocular malignancy that accounts for 5% of all melanomas.  It can be classified by anatomical locations which includes the commonly benign iris melanomas and the malignant ciliary body and choroidal melanomas. 

Patients may present with gradual vision loss, metamorphopsia, visual field loss and photopsia. Many may also be asymptomatic if the lesion does not impede the macula. Retinal signs of early melanomas includes a solitary elevated domed shape mass which may be pigmented or amelanotic, lipofuscin in the RPE overlying the lesion, choroidal folds and a “collar stud” appearance of mass if the tumour has penetrated through Bruch’s membrane.

The condition is diagnosed clinically by fundus examination and ultrasonography. When the origin of the melanoma is unknown, genetic testing with tissue biopsy using technique such as trans-scleral and trans-vitreal aspiration with a fine 25 gauge needle can be performed.

Management of uveal melanomas range from conservative therapies such as laser photocoagulation, radiotherapy, transpupillary thermotherapy and photodynamic therapy to the more invasive surgical procedures such as, trans scleral choroidectomy, enucleation(removing the globe only), evisceration (removing the inner contents of the eye and leaving the globe) and exenteration (removing all contents of the orbit).

Survival rates of patients with melanomas vary depending on time of diagnosis and treatment. Some studies show that the five year survival rates for patients assigned with enucleation alone was 57% and 62% for patients assigned to pre-enucleation radiation. Ten year survival rates was 39% for both methods of management.

 

Conclusion

Mr X. diagnosed with a choroidal melanoma that was 16mm horizontally and 20mm in depth in the far temporal retina with no systemic metastasis. He was placed on the waiting list for a LE enucleation. It was noted that early liver metastasis is unknown due to limitations of current diagnostic technology. 

This case highlights the dangers of uveal melanomas and emphasizes the importance of comprehensive peripheral retinal examinations on all patients as it could save lives.

  

References

  1. Sodhi A, Gutkind S. Molecular Genetic of Choroidal Melanoma. Ryan’s Retina. 6th ed. USA: Elsevier; 2018 
  1. Damato B, Stewart J, Afshar A, Groenewald C, Foulds W. Surgical resection of the Choroidal Melanoma. Ryan’s Retina. 6th ed. USA: Elsevier; 2018
  1. Hawkins B, Schachat A. Collaborative Ocular Melanoma Study. Ryan’s Retina. 6th ed. USA: Elsevier; 2018
  1. Herwig M, Grossniklaus H. Pathology of Choroidal Melanoma. Ryan’s Retina. 6th ed. USA: Elsevier; 2018
  1. Kanski J, Bowling B, Nischal K, Pearson A. Clinical Ophthalmology: A Systemic Approach. 7th ed. United Kingdom: Elsevier; 2011.
  1. Shields C, Shields J. Overview of management of Posterior Uveal Melanoma. Ryan’s Retina. 6th ed. USA: Elsevier; 2018 
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