Choroidal melanoma masquerading as multifocal central serous chorioretinopathy.

A 56 year-old-male presented with diminution of vision in right eye of 2 months duration. His best corrected visual acuity (BCVA) was 20/25. Anterior segment examination was bilaterally normal. Right fundus revealed oval, raised, pigmented lesion in superotemporal quadrant with subfoveal fluid. Fundus fluroscein angiography (FFA) showed multiple pinpoint leakages. Acoustic hollowing on ultrasound (USG) was typical of choroidal melanoma. A high index of suspicion is required for the diagnosis of small choroidal melanoma that could present with multiple focal leaks and subretinal fluid simulating multifocal central serous retinopathy (CSR).

A 56-year-old-male presented with diminution of vision in right eye of 2 months duration. His best corrected visual acuity was 20/25. Anterior segment examination was bilaterally normal except for early cataractous changes. Left fundus was normal. Right fundus revealed areas of pigmentary alterations and subfoveal fluid [Figure 1]. Indirect ophthalmoscopy revealed an oval, raised, pigmented lesion in superotemporal quadrant with hyper-autofluorescence extending to the area of subretinal fluid (SRF) [Figure 2]. Fundus fluorescein angiography showed multiple pinpoint leakages [Figure 3], while indocyanine green angiography revealed blocked fluorescence [Figure 4]. Acoustic hollowing on ultrasound (USG) was typical of choroidal melanoma [Figure 5a]. Optical coherence tomography confirmed SRF [Figure 5b] overlying the tumor.

Figure 1

Fundus photograph of right eye (a) reveals shallow subretinal fluid at fovea. Left fundus is normal (b). Optical coherence tomography of right eye (c) confirms subretinal fluid. Left eye Optical coherence tomography is normal (d)

Figure 2

An oval, raised, pigmented lesion in superotemporal quadrant (a) with orange pigment (left arrows) and subretinal fluid (right arrow). Hyper-autofluorescence (b) is seen extending to the area of subretinal fluid and orange pigment

Figure 3

Images from early (a), mid (b) and late (c) phases of arteriovenous fundus fluroscein angiography reveal multiple, pin-point hyperfluorescent spots along the superotemporal arcade increasing in size and intensity over time. Fluorescein angiography montage (d) reveals the extent of the tumor and multiple leakage points

Figure 4

Indocyanine green angiography montage reveals blocked fluorescence

Figure 5

Ultrasound scan (a) revealed tumor thickness 2.6 mm with acoustic hollowing typical of choroidal melanoma. Optical coherence tomography scan confirmed subretinal fluid (b) overlying the tumor

A mnemonic for easy diagnosis of small melanoma is “To find small ocular melanoma using helpful hints daily”, where T: Thickness >2 mm, F: Subretinal fluid, S: Symptoms, O: Presence of orange pigment, M: Tumor margin within 3 mm of optic disc, H: USG hollowness, H: Halo absence, and D: Drusen absent.[1234] Seven of these eight risk factors were present in this case, and diagnosis of small choroidal melanoma was established. Metastatic workup, including USG abdomen, chest X-ray, and liver function test, was normal.

A high index of suspicion is required for the diagnosis of small choroidal melanoma that could present with multiple focal leaks and SRF simulating multifocal central serous retinopathy.

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