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An Echodense Choroidal Lesion in an Elderly Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

An 89-year-old asymptomatic woman presented to a new eye care professional for a routine examination. Examination findings showed a large choroidal mass in the left eye suspicious for a malignant neoplasm. The patient’s ocular history showed a cataract surgical procedure, YAG capsulotomy, and subsequent repair of retinal detachment with scleral buckle and pneumatic retinopexy in the left eye approximately 30 years earlier. Ophthalmoscopic examination results of the left eye revealed a peripheral retinal atrophy from previous cryotherapy treatment. A large choroidal mass was observed in the inferotemporal region. The patient was referred for further evaluation of the mass, which was suspected to represent choroidal melanoma.

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Choroidal pseudomelanoma secondary to scleral buckle

D. Suspect an association with prior ocular surgery

Choroidal melanoma is the most common primary intraocular malignant neoplasm in the United States, affecting 5.2 per million population.1 Pseudomelanoma is a condition that simulates choroidal melanoma. In an analysis of approximately 12 000 patients referred to a tertiary care center with uveal melanoma over a 25-year period, 1739 (14%) proved to be pseudomelanoma.2 Of these, the most common pseudomelanomas included choroidal nevus (851 [49%]), peripheral exudative hemorrhagic chorioretinopathy (139 [8%]), and congenital hypertrophy of the retinal pigmented epithelium (108 [6%]).2 Much less commonly, compression by an orbital mass (3 [0.2%]) was noted, as in this case with compression by a radial scleral sponge.

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Article Information

Corresponding Author: Carol L. Shields, MD, Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut St, Ste 1440, Philadelphia, PA 19107 (carolshields@gmail.com).

Published Online: March 25, 2021. doi:10.1001/jamaophthalmol.2020.4642

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported in part by the Eye Tumor Research Foundation, Philadelphia, Pennsylvania (Dr Shields).

Role of the Funder/Sponsor: The Eye Tumor Research Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Aronow  ME , Topham  AK , Singh  AD .  Uveal melanoma: 5-year update on incidence, treatment, and survival (SEER 1973-2013).   Ocul Oncol Pathol. 2018;4(3):145-151. doi:10.1159/000480640 PubMedGoogle ScholarCrossref
2.
Shields  JA , Mashayekhi  A , Ra  S , Shields  CL .  Pseudomelanomas of the posterior uveal tract: the 2006 Taylor R. Smith Lecture.   Retina. 2005;25(6):767-771. doi:10.1097/00006982-200509000-00013 PubMedGoogle ScholarCrossref
3.
Shields  CL , Demirci  H , Marr  BP , Mashayekhi  A , Materin  MA , Shields  JA .  Expanding MIRAgel scleral buckle simulating an orbital tumor in four cases.   Ophthalmic Plast Reconstr Surg. 2005;21(1):32-38. doi:10.1097/01.IOP.0000148409.31127.F5 PubMedGoogle ScholarCrossref
4.
Motiani  MV , Almanzor  R , McCannel  TA .  Scleral buckle-associated ciliochoroidal melanoma.   Semin Ophthalmol. 2017;32(4):514-516. doi:10.3109/08820538.2015.1115090 PubMedGoogle ScholarCrossref
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