Choroidal hematoma presenting as pseudo-uveal melanoma in a monocular 47-year-old Asian Indian lady with opaque media.

Pseudomelanoma is a condition that mimics a uveal melanoma. Various methods are used to differentiate between uveal melanoma and mimicking conditions, but none is definitive. We report a case of localized hemorrhagic choroidal detachment in monocular middle-aged Asian lady of Indian origin with opaque media secondary to failed corneal graft. An ultrasound scan revealed a mass lesion suspected to be choroidal melanoma. After 10 weeks of observation and follow-up, lesion showed complete regression as seen with serial ultrasound scans. This case is being presented for its rarity and unique presentation in a bilaterally blind patient with spontaneous resolution of pseudomelanoma documented with serial imaging.

Introduction

Malignant melanoma of the uveal tract is rare among Asian Indians.[1] Because of the relative rarity of the condition, and sometimes lack of symptoms, it is not often detected early in its clinical course. At 10 years follow-up, metastasis was found in 25% patients with choroidal melanoma.[2] Hence, there is importance of having a high suspicion for this entity, especially in a monocular patient with no fundus view. We report a case of choroidal hematoma presenting as “pseudo-uveal melanoma” imaged with serial ultrasonography (USG) scans and complete regression with observation at 10 weeks follow-up.

Case Report

A 47-year-old female presented with redness, pain, watering, and aversion to light in the left eye of 2 days duration. There was no history of ocular trauma. The right eye had no light perception of unknown cause since childhood. Relevant ocular history revealed penetrating keratoplasty in the left eye, done 33 years back, elsewhere [Figure 1]. Left eye examination revealed ciliary congestion and a perforated corneal ulcer within the opaque corneal graft. She underwent corneal scraping, followed by application of isoamyl 2-cyanoacrylate glue (0.25 ml; Concord drugs limited, Anantpur, India) and bandage contact lens. USG of the left eye revealed a localized, dome-shaped, peripapillary retinochoroidal mass, with moderate-to-high surface reflectivity and low-to-moderate inner reflectivity. Retinal detachment and “T” sign were absent [Figure 2]. She was suspected to have choroidal melanoma. Differential diagnosis included choroidal hematoma, choroidal metastasis, choroidal granuloma, posterior scleritis, and thrombosed varix of vortex vein. Choroidal hematoma (i.e., localized hemorrhagic choroidal detachment) was suspected because of the recently perforated globe.

Figure 1

External photograph reveals bilateral leukomatous corneal opacity

Figure 2

(a and b) Ultrasonography (USG) of the left eye shows a localized, dome-shaped, peripapillary retinochoroidal mass lesion of 14.1 mm × 10.7 mm × 5.7 mm in size, with moderate-to-high surface reflectivity and low-to-moderate inner reflectivity

Magnetic resonance imaging (MRI) revealed a lenticular-shaped, hyperintense lesion in the left eye. It was isointense on T2 [Figure 3]. Positron emission tomography (PET) scan did not reveal any systemic metastasis. After 1 month, slit lamp examination showed sealed corneal perforation, and USG revealed drastically decreased size of the mass lesion [Figure 4a and 4b]. Eventually, serial USG showed complete resolution of retinochoroidal mass after 10 weeks from date of diagnosis [Figure 4c].

Figure 3

(a) Magnetic resonance imaging, sagittal section, T1 fat suppressed and fluid-attenuated inversion recovery revealed a lenticular-shaped hyperintense lesion in the superior quadrant of the left eyeball abutting the choroidal surface (14 mm × 12 mm × 7 mm – TR × AP × CC). (b) Magnetic resonance imaging T1 fat suppressed with contrast study, sagittal section: lesion remains hyperintense

Figure 4

(a) Baseline USG of the left eye shows a retinochoroidal mass lesion of 14.1 mm × 10.7 mm × 5.7 mm in size. (b) Serial USG after 4 weeks revealed drastically decreased size of retinochoroidal mass to 2.6 mm × 2.6 mm × 1 mm. (c) Complete resolution of retinochoroidal mass after 10 weeks from date of diagnosis

Discussion

Uveal melanoma is often misdiagnosed by general ophthalmologists.[34] In the collaborative ocular melanoma study, the misdiagnosis rate was 0.48%. Differentiation between melanoma and pseudo-melanoma is possible with various methods including clinical features, with an accuracy of up to 98% when performed by an ophthalmic oncologist.[5] Other modalities including fluorescein angiography, USG findings, ultrasound biomicroscopy, single photon emission computerized tomography, and PET may add more accuracy.

In our case, history of sudden hypotony and media opacity precluded evaluation of clinical features. Findings on USG and MRI were consistent with medium to large choroidal melanoma. Metastasis was ruled out on PET scan. In the given clinical situation, the possibility of localized choroidal hematoma far outweighed the probability of uveal melanoma. Once perforation was sealed, we observed the case, and serial USG scans showed signs of regression. In our case, localized suprachoroidal hemorrhage did masquerade as posterior uveal melanoma posing a challenge for an accurate diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.