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Skin Cancer

A Pigmented Epiretinal Membrane in the Eighth Decade of Life

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

1 Credit CME

JAMA Ophthalmology

Published Online: October 13, 2022

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

André Borges Silva, MD^1,2;

João Figueira, MD, PhD^1,3;

Cristina Fonseca, MD^1,3

Author Affiliations

¹Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
²Centro Hospitalar Tondela-Viseu, Viseu, Portugal
³Faculty of Medicine, University of Coimbra, Coimbra, Portugal

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A 75-year-old woman presenting with decreased visual acuity and metamorphopsia in the right eye was referred for further evaluation of a pigmented epiretinal membrane. She had a history of cutaneous nodular melanoma in the right arm. Tumor staging was classified as T3N0M0 in August 2017, at the time of diagnosis and excision. In April 2018, axillary lymphadenectomy was performed for local recurrence and the patient started treatment with an immune checkpoint inhibitor (ICI) pembrolizumab, without further local or metastatic evidence of the tumor. Ocular history was positive for cataract surgery bilaterally. After cataract surgery in the right eye, an asymptomatic vision loss was noted and the cause was attributed to the presence of choroidal neovascularization (CNV), for which the patient underwent intravitreal anti–vascular endothelial growth factor (anti-VEGF) injections.

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Cutaneous melanoma metastatic to the vitreous cavity and deposition of melanoma cells over the epiretinal membrane

C. Perform pars plana vitrectomy and excisional biopsy of the membrane

The patient underwent diagnostic and therapeutic pars plana vitrectomy (Figure 2) during which vitreous biopsy and epiretinal membrane peeling were performed. Pathology and immunohistochemistry of the membrane and cytology of the vitreous confirmed the diagnosis of metastatic cutaneous melanoma (CM) (Figure 2).

Metastasis is the most common intraocular neoplasia and is most commonly associated with primary breast and lung tumors; however, the eye is an unusual site for CM metastasis, and when it occurs, the most common site of involvement is the choroid.¹^,2 In contrast, the vitreous is an exceptionally rare site of metastasis for any cancer, including CM. A large recent multicenter case series revealed that the median age at presentation for vitreous CM metastasis was 66 years, the median time from starting immunotherapy to ocular symptoms was 17 months, and 10 of 11 patients were treated with ICIs at some point in the treatment course.² This is consistent with our case findings.

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Article Information

Corresponding Author: André Borges Silva, MD, Centro Hospitalar Tondela-Viseu, Av. Rei Dom Duarte, 3504-509 Viseu, Portugal (abds.90@hotmail.com).

Published Online: October 13, 2022. doi:10.1001/jamaophthalmol.2022.3949

Conflict of Interest Disclosures: Dr Figueira reported nonfinancial support from Alcon and Roche and personal fees from AbbVie, Alimera, Novartis, and Bayer outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank Miguel Ribeiro, MD, for the patient referral, Nuno Gouveia, MD, who helped capture the optical coherence tomography and fundus images in the Ophthalmology Department, and Graça Fernandes, MD, and Barbara Sepodes, MD, who provided the photomicrograph showing cytopathologic results of epiretinal membrane biopsy sample. We also thank the patient for granting permission to publish this information.

References

Francis JH , Berry D , Abramson DH , et al. Intravitreous cutaneous metastatic melanoma in the era of checkpoint inhibition: unmasking and masquerading. Ophthalmology. 2020;127(2):240-248. doi:10.1016/j.ophtha.2019.09.018 PubMed Google Scholar Crossref

Shields CL , Shields JA , Gross NE , Schwartz GP , Lally SE . Survey of 520 eyes with uveal metastases. Ophthalmology. 1997;104(8):1265-1276. doi:10.1016/S0161-6420(97)30148-1 PubMed Google Scholar Crossref

Xin Yu J , Hubbard-Lucey VM , Tang J . Immuno-oncology drug development goes global. Nat Rev Drug Discov. 2019;18(12):899-900. doi:10.1038/d41573-019-00167-9 PubMed Google Scholar Crossref

Abdel-Rahman O , Oweira H , Petrausch U , et al. Immune-related ocular toxicities in solid tumor patients treated with immune checkpoint inhibitors: a systematic review. Expert Rev Anticancer Ther. 2017;17(4):387-394. doi:10.1080/14737140.2017.1296765 PubMed Google Scholar Crossref

Mitchell P , Liew G , Gopinath B , Wong TY . Age-related macular degeneration. Lancet. 2018;392(10153):1147-1159. doi:10.1016/S0140-6736(18)31550-2 PubMed Google Scholar Crossref

Wladis EJ , Kambam ML . Ophthalmic complications of immune checkpoint inhibitors. Orbit. 2022;41(1):28-33. doi:10.1080/01676830.2020.1867192 PubMed Google Scholar Crossref

Fang T , Maberley DA , Etminan M . Ocular adverse events with immune checkpoint inhibitors. J Curr Ophthalmol. 2019;31(3):319-322. doi:10.1016/j.joco.2019.05.002 Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.