Choroidal metastasis masquerading as anterior and posterior scleritis

Theme: Uveitis
What: Uveitis
Part of: Uveitis II: Advancements in Uveitis Diagnosis and Management / Uvéite II: Avancées dans le diagnostic et la prise en charge de l’uvéite
When: 5/31/2024, 02:00 PM - 03:30 PM
Where: Room | Salle 714 B

Abstract

Purpose: Choroidal metastasis can present with visual symptoms like blurry vision, flashes and floaters, but rarely redness and pain. We describe here an unusual presentation of choroidal melanoma metastasis from a cutaneous primary, initially manifesting as anterior and posterior scleritis.

Study Design: Case report.

Methods: Retrospective analysis of BSCR patients' initial symptoms from medical records, data analyzed statistically.

Results: A 70-year-old man with no neoplastic history but a familial history of colon cancer presented with redness and pain, without photophobia. On initial examination, visual acuity was 20/50+2 in the right eye (OD) and 20/20-1 in the left eye (OS), with intraocular pressures of 18 mmHg OD and 12 mmHg OS. Physical examination revealed scleral vessel dilation nasally and supero-nasally with pain on palpation consistent with anterior scleritis OD. On MRI, a choroidal nodular non-pigmented mass located nasal to the optic nerve OD, measuring 7 x 3 mm, was observed. This mass measured 5DD x 2DD on fundus exam and 13.6 x 5.9 mm on B-scan a few weeks later. Additionally, fundus examination OD revealed peripheral choroidal detachments. Examination of the contralateral eye was unremarkable except for a small retinal tear that was treated with laser. Prednisolone, atropine drops and oral corticotherapy were provided after excluding infections.

Routine colonoscopy biopsied polyps with a diagnosis of melanoma. A suspicious scalp lesion was biopsied, testing positive for MelanA and SOX10 but negative for AE1/3 in immunohistochemistry. There was absence of BRAF mutation but NRAS was positive. A PET scan revealed numerous hypermetabolic hypodense hepatic lesions and multicentric metastatic involvement in infra-diaphragmatic, hepatic, splenic, muscular, and osseous lymph nodes. These findings suggested melanoma metastasis. Subsequently, cerebral MRI revealed multiple intracranial metastatic lesions with potential hemorrhagic components.

Following two immunotherapy cycles, metastatic progression persisted along with headache, scotoma and a 3 day blurred vision episode OD. Eye examination revealed vitreous hemorrhage OD and MRI showed slight growth in the right ocular mass and new or progressing hemorrhagic components of the ocular and intracranial lesions. On final follow-up, visual acuity was 20/50-2 OD and 20/20 OS, with slight progression of the OD choroidal mass and no signs of scleritis or intraocular inflammation. In addition to immunotherapy, the patient was offered local ocular and cerebral palliative radiotherapy, aiming to reduce lesion size, preserve vision and minimize discomfort.

Conclusion: Recognizing that neoplasia can mimic inflammatory disorders such as scleritis is crucial. Moreover, primary choroidal melanoma can be difficult to distinguish from melanoma metastasis. Raising awareness of such atypical presentations is essential for early diagnosis and management.

Presenter(s)

Presenting Author: Daniel R. Chow

Additional Author(s):

Mélanie Hébert, Ophthalmology Resident - (Université Laval)

Marie-Josée Aubin, Université de Montreal

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