Sudden ocular pain from underlying mass.

Case

A 60-year-old Caucasian woman was referred for headache and severe pain in her left eye (OS for five days). The patient initiated 800 mg of ibuprofen, which provided little pain relief. Past medical history revealed cerebrovascular accident and gastroesophageal reflux, controlled on medications. Past surgical history included cholecystectomy and knee replacement. Computed tomography (CT) scan of the head showed no evidence of intracranial mass or recurrent stroke. On ophthalmic examination, visual acuity was 20/20 in both eyes. Intraocular pressures were 11 mmHg in the right eye (OD) and 8 mmHg OS. Slit lamp examination was normal OD and showed conjunctival chemosis OS.

What is Your Next Step?

Start on prednisolone acetate eye drops twice daily.

Increase ibuprofen dosage.

Dilated fundus examination.

Repeat CT scan.

Findings

Funduscopy revealed a pigmented hemorrhagic choroidal mass in the inferonasal periphery with overlying subretinal fluid, intraretinal hemorrhage and vitreous hemorrhage [Fig. 1a]. Ultrasonography showed a dome-shaped, acoustically hollow lesion, measuring 6.4 mm in thickness and with overlying vitreous echoes and subtle episcleral Tenon's fascia edema [Fig. 1b]. On optical coherence tomography, the fovea was normal, but there was mild vitreous hemorrhage causing linear retinal shadowing [Fig. 1c] and retinal detachment extending to near the inferior arcade [Fig. 1d]. Choroidal melanoma with tumor necrosis was diagnosed and treated with plaque radiotherapy with a tumor apex dose of 70 Gy over 102 hours. Chemosis improved following ibuprofen therapy.

Figure 1

Funduscopy revealed a pigmented hemorrhagic choroidal mass in the inferonasal periphery with overlying subretinal fluid, intraretinal hemorrhage and vitreous hemorrhage (a). Ultrasonography showed a dome-shaped, acoustically hollow lesion, measuring 6.4 mm in thickness and with overlying vitreous echoes and subtle episcleral Tenon's fascia edema (b). On optical coherence tomography, (c) the fovea was normal, but there was mild vitreous hemorrhage causing linear retinal shadowing. (d) Retinal detachment extended to near the inferior arcade

Diagnosis

Uveal melanoma with tumor necrosis.

Correct Answer:

C. Dilated fundus examination.

Discussion

Uveal melanoma usually presents as a painless, pigmented choroidal tumor. Symptoms include blurred vision, photopsia, floaters, and <1% of patients experience pain.1 Eye pain is attributed to neovascular glaucoma or spontaneous tumor necrosis,[12] which may induce conjunctival or scleral inflammation, as seen in this case.[3] In a series of 15 patients with melanoma-related pain, mean tumor thickness was 6.1mm. The pain was severe, lasting a median of 7 days with resolution after plaque radiotherapy (67%) and periocular triamcinolone.[1]

Conclusion

All patients with severe eye pain should have a dilated fundus examination, to look for inflammatory, infectious, traumatic, glaucomatous, and neoplastic sources.

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.