Disappearance of ocular malignant melanoma on computerised scan after spontaneous necrosis: clinical, radiological and pathological features

Necrotic Uveal Melanoma Mimics Orbital Cellulitis: A Review

Background

Uveal melanoma is the most common primary intraocular malignancy in adults, often resulting in painless vision loss. We report a case of necrotic uveal melanoma presenting with orbital inflammation mimicking orbital cellulitis and present a comprehensive review of the literature and tabulation of reported cases.

Summary

Our review found 44 published reports of spontaneously necrotic uveal melanoma involving 55 patients. Of these reports, 26 patients (47%) presented with orbital cellulitis. Presenting symptoms of necrotic uveal melanoma with orbital cellulitis included proptosis (82.8%), pain (80.7%), vision loss (61.5%), and restricted extraocular movements (46.2%).

Key Messages

Uveal melanoma can rarely mimic orbital cellulitis. Autoinfarction and tumor necrosis causes secondary orbital inflammation. Intraocular malignancy must remain in the differential for patients with orbital inflammation and vision loss.

Inadvertent evisceration of eyes containing uveal melanoma

OBJECTIVES

To report an important complication of ocular evisceration therapy for blind, painful eyes that has been unreported in the literature, and to stress the need for careful preoperative evaluation to exclude occult neoplasms prior to therapy.

DESIGN

Multicenter, retrospective, nonrandomized clinicopathological case series of patients found to have previously unsuspected uveal malignant melanoma during histopathological examination of blind, painful eyes treated by evisceration.

RESULTS

Histopathological examination of evisceration specimens disclosed previously unsuspected uveal melanoma in 7 patients who were treated for blind, painful eyes. Inflammation caused by necrosis of the tumor and other ocular tissues led to misdiagnosis as endophthalmitis, orbital cellulitis, or idiopathic orbital inflammation in several cases. Preoperative imaging was not performed in 3 cases and failed to detect tumors in the remaining 4 cases. Failure of necrotic tumors to enhance contributed to misdiagnosis.

CONCLUSIONS

The presence of a malignant intraocular neoplasm should be excluded prior to evisceration of any blind eye or blind, painful eye, particularly with opaque media. Necrosis-related inflammation can confound the clinical diagnosis of occult lesions, as can failure of necrotic tumors to enhance on imaging studies.

Necrotic uveal melanoma with orbital inflammation

PURPOSE

Extraocular extension of uveal melanoma can be accompanied by proptosis and signs of orbital inflammation but this clinical presentation is an uncommon feature if the tumor is solely intraocular.

METHODS

Case report.

RESULTS

The authors describe a patient with a medium-sized necrotic uveal melanoma, without extraocular spread, presenting with the clinical picture of orbital cellulitis.

CONCLUSIONS

The ophthalmologist needs to be aware of this uncommon presentation of uveal melanoma, and not assume the presence of proptosis and orbital inflammation as signs of extraocular extension.

Orbital inflammation in a patient with extrascleral spread of choroidal malignant melanoma

An elderly woman presented with fever, dehydration, orbital inflammation, total external and internal ophthalmoplegia and blindness, resembling the clinical appearance at presentation of severe orbital inflammatory disease or mucormycosis. Orbital computed tomography scanning demonstrated a retrobulbar orbital mass. Subsequent B-scan ultrasound examination confirmed the orbital mass but also demonstrated a mass within the eye. At lateral orbitotomy, extrascleral spread of an entirely necrotic intraocular melanoma was demonstrated. As computed tomography scanning may not be able to delineate an entirely necrotic intraocular malignant melanoma, B-scan ultrasonography should be considered in patients with orbital inflammation, especially in the presence of a retrobulbar mass.