Optometry case study: Choroidal metastasis

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By Trinh Trinh, Specsavers Mount Barker, SA

History

Px: 67-year-old male
Reason for visit: A routine ocular examination. No symptoms of blurred vision, headaches or eye pain and no signs of flashes or floaters.
General health: Recently stopped chemotherapy for carotid gland adenocarcinoma

Clinical Assessment

VA: RE: 6/6  L: 6/6  OU: 6/6
IOPs: RE: 18 mmHg  LE: 20mmHg
Fundus examination: Unremarkable in RE. LE noted a yellow circular lesion with indistinct borders along superior arcade.
OCT: LE: Convex retinal profile with sub-retinal fluid consistent with serous neurosensory detachment (Figure 1)

Figure 1. OCT widefield report for LE

Diagnosis & Management

Differential diagnosis:

  • Choroidal melanoma
  • Choroidal hemangioma
  • Choroidal granuloma
  • Choroidal neovascularisation with disciform scar

Provisional diagnosis: Choroidal melanoma

Management: The patient was referred to the local ophthalmologist who referred him to an ocular oncologist.

Discussion

Choroidal metastasis commonly occurs in patients with a known history of systemic cancer. In this case, the patient had a history of carotid gland adenocarcinoma. In most clinical presentations, 70-81%1 of patients experience blurred vision and about 5-12%1 of cases have no symptoms or visual complaints of flashes and floaters.

In optometry practice, choroidal melanoma can be detected by performing fundoscopy, digital retinal scans and optical coherence tomography (OCT). OCT provides an adjunctive diagnostic tool for evaluating and detecting retinal structural changes secondary to choroidal metastases1.

However, clinical evaluation and A- and B-ultrasounds are the gold standard for diagnosing choroidal melanoma. Other diagnostic techniques include auto-fluorescence, fluorescein angiography, MRI and invasive needle aspiration biopsy2.

Choroidal metastases are a sign of advanced metastatic disease with poor prognosis; therefore, identifying the location of the primary tumour is imperative for appropriate treatment3. Treatment involves a multidisciplinary team of ophthalmologists, oncologists and radiation oncologists. Treatment options include systemic hormonal therapy, immunotherapy, chemotherapy, radiotherapy or enucleation2,3.


REFERENCES
1. 2013 Nov; 61(11); 663-664. doi: 10.4103/0301-4738.121148. Epubmed. Morphological features of choroidal metastases: An OCT analysis. L Ianetti, R Zito, P Tortorella.

2. 2015 Feb; 63(2): 122-127. doi: 10.4103/0301-4738.154380. Epubmed. Choroidal metastases; Origin, features and therapy. S Arepalli, Kaliki S, C Shields.

3. Surv Ophthalmology. 2011 Nov-Dec; 56(6) 511-521 doi: 10.1016/j.survophthal.2011.05.001. Epubmed. Emerging treatments for choroidal metastases. Chen C, A McCoy, J Brahmer, J Handa

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