Hemorrhagic complication in an unsuspected macular choroidal melanoma

Hemorrhagic choroidal detachment as the presenting sign of uveal melanoma

Purpose

To describe two cases of medium-sized uveal melanoma presenting with hemorrhagic choroidal detachments.

Observations

The first case is a 39-year-old man who presented with choroidal hemorrhage and angle closure glaucoma. The second case is a 42-year-old man who presented with choroidal hemorrhage and posterior scleritis. Vitrectomy with transvitreous fine needle aspiration biopsy was ultimately required to diagnose malignant uveal melanoma in each case.

Conclusions and importance

Intraocular hemorrhage is a rare presenting sign of uveal melanoma. When it does occur, it is typically associated with large tumors. Hemorrhagic choroidal detachments are particularly rare in uveal melanoma, and can limit the diagnostic utility of clinical exam, B-scan ultrasonography, and magnetic resonance imaging. Although it is uncommon, it is important to maintain a high index of suspicion for choroidal melanoma in any patient with unexplained choroidal hemorrhage.

Unusual presentation of a choroidal melanoma

A 49-year-old gentleman presented with a 1-day history of painful deterioration of vision in his right eye. He was lifting heavy weights just before this visual loss. On examination, his vision was perception of light in that eye, with a medically uncontrollable high intraocular pressure and hyphaema almost completely filling his anterior chamber. An ultrasound performed suggested a working diagnosis of a Valsalva related 'eight ball' bleed. After an anterior chamber washout, he had another episode of bleeding three days later. A pars plana vitrectomy was performed and the sample obtained was sent off to the laboratory, revealing a choroidal melanoma. Following enucleation, the histology confirmed a large necrotic spindle cell melanoma, with a haemorrhagic background. Fortunately, no liver metastasis was found. Since his diagnosis 3 years ago, he continues to be followed up in an artificial eye clinic and has regular liver scans under the care of his oncologist.

Hemorrhagic choroidal melanoma

Purpose

To demonstrate the clinical pathologic correlation in a hemorrhagic choroidal melanoma.

Observations

A 52 year old patient presented with a large choroidal mass associated with vitreous and retinal hemorrhage. The eye was enucleated and histopathology demonstrated epithelioid-type MART1 positive tumor cells consistent with choroidal melanoma. The tumor had broken through Bruch's membrane, which led to localized vascular compression with bleeding into the subretinal space, retina and vitreous.

Conclusions and importance

Choroidal melanoma rarely presents with hemorrhage. Tumor rupture through Bruch's membrane may result in a tourniquet effect on the tumor vasculature leading to massive hemorrhage, as in this case. A high level of clinical suspicion is required to make the diagnosis.

Extensive submacular haemorrhage in polypoidal choroidal vasculopathy managed by sequential gas displacement and photodynamic therapy: a pilot study of one-year follow up

BACKGROUND

Polypoidal choroidal vasculopathy (PCV) with peculiar vascular lesions presents frequently as recurrent submacular haemorrhage. The best treatment is still not certain. It is the authors' objective to evaluate the 1-year safety and efficacy of photodynamic therapy (PDT) using verteporfin for persistent macular PCV after pneumatic displacement of the massive submacular haemorrhage with intravitreal perfluoropropane (C(3)F(8)).

METHODS

A prospective, non-comparative, interventional case series on patients with extensive and thick submacular haemorrhage secondary to PCV, which was displaced pneumatically with intravitreal pure 0.4 ml C(3)F(8). Fluorescein angiography and indocyanine green angiography were repeated 1-2 weeks later to delineate any persistent active leaking polypoidal lesions, which were then treated with PDT. Retreatment might be considered in each follow up at every 3 months.

RESULTS

Six eyes of six patients with the mean age of 53.6 years had been recruited and completed 1-year follow up. The mean baseline Snellen equivalent best-corrected visual acuity (BCVA) was 6/92 and the mean final BCVA at 1 year was 6/17. The mean improvement in logMAR BCVA after the sequential treatments was seven lines (range +3 to +19 lines) (Wilcoxon signed-ranks test, P = 0.03). All patients had at least moderate visual gains. No patient suffered serious complications from PDT.

CONCLUSIONS

This first report on combined treatment with intravitreal gas injection and sequential PDT on PCV seems to be a well-tolerated option. Further comparative studies with larger sample size and longer follow up are warranted.