Pseudomelanoma: occult intraocular foreign body mimicking choroidal melanoma

oc000211 10.3205/oc000211 urn:nbn:de:0183-oc0002115 Case Report Pseudomelanoma: occult intraocular foreign body mimicking choroidal melanoma Yılmaz Çebi Yılmaz Çebi Aslıhan A

Ophthalmology Department, Çerkezköy State Hospital, Tekirdağ, Turkey

author Batu Oto Batu Oto Bilge B

Ophthalmology Department, Cerrahpaşa Faculty of Medicine, Istanbul University – Cerrahpaşa, Istanbul, Turkey

author Kılıçarslan Kılıçarslan Oğuzhan O

Ophthalmology Department, Ayancık State Hospital, Sinop, Turkey

author Sarıcı Sarıcı Ahmet Murat AM

Ophthalmology Department, Cerrahpaşa Faculty of Medicine, Istanbul University – Cerrahpaşa, Koca Mustafapaşa Cd. No:53 D:No:53, 34096 Istanbul, Turkey, Phone: +90 5305146854Ophthalmology Department, Cerrahpaşa Faculty of Medicine, Istanbul University – Cerrahpaşa, Istanbul, Turkey

ahmetsarici@gmail.com author German Medical Science GMS Publishing House

Düsseldorf

610 choroid hemorrhage choroid neoplasms choroidal neovascularization foreign bodies eye injuries Aderhautblutung Aderhautneoplasmen choroidale Neovaskularisation Fremdkörper Augenverletzungen 2023013020230203 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2193-1496 13 GMS Ophthalmology Cases GMS Ophthalmol Cases 03 20230203The initial of the author Kılıçarslan has been corrected. Purpose: To report an occult intraocular foreign body mimicking choroidal melanoma. Methods: Medical records and imagings of the patient were retrospectively reviewed.Case description: A 76-year-old male was referred to our ocular oncology clinic with a suspicious hyperpigmented retinal lesion in the left eye. Biomicroscopy showed aphakia and peripheral iridectomy in the left eye. Fundoscopy revealed a pigmented, slightly elevated lesion on the macula of the left eye surrounded by diffuse atrophy. B-scan ultrasonography showed a preretinal hyperechoic lesion with posterior shadowing. There was no choroidal mass in B-scan or optical coherence tomography (OCT) imaging. On further questioning, it was disclosed that the patient had been hit by an iron fragment in the left eye forty years ago.Conclusion: Choroidal melanoma is a vision- and life-threatening intraocular malignant tumour. Various neoplastic, degenerative, and inflammatory conditions can simulate choroidal melanoma. A previous history of penetrating ocular trauma should lead the surgeon to re-evaluate a diagnosis of melanoma. IntroductionChoroidal melanoma is a vision- and life-threatening intraocular malignant tumour. Choroidal melanoma usually presents itself as a pigmented mass in fundoscopic examination. Treatment approaches include transpupillary thermotherapy, plaque radiotherapy, local resection, enucleation, or orbital exenteration . Various neoplastic, degenerative and inflammatory conditions such as choroidal nevus, congenital hypertrophy of the retinal pigment epithelium, hemorrhagic retina pigment epithelium (RPE) detachment, massive subretinal hemorrhage due to neovascular age-related macular degeneration, choroidal hemangioma, peripheral exudative hemorrhagic chorioretinopathy, RPE hyperplasia, optic disc melanocyto</PlainText></TextGroup>ma, solitary choroiditis, nodular posterior scleritis, and staphyloma can simulate choroidal melanoma <TextLink reference="1"></TextLink>, <TextLink reference="2"></TextLink>. Due to the novel examination techniques and increased familiarity with confusing lesions, diagnosis has become more accurate in recent years. Among these pseudomelanomas, a retained ocular foreign body is a rare cause. We report a case of occult intraocular foreign body which mimics choroidal melanoma.</Pgraph></TextBlock> <TextBlock linked="yes" name="Case description"> <MainHeadline>Case description</MainHeadline><Pgraph>A 76-year-old man with the suspicion of choroidal melanoma in his left eye was referred to our ocular oncology clinic. The best corrected visual acuity was 0.7 in the right eye, and hand movement from 30 cm in the left eye. On biomicroscopy cortical cataract in the right eye, and aphakia and peripheral iridectomy in the left eye were noted. Fundoscopy revealed posterior vitreous detachment in the right eye and a pigmented, slightly elevated lesion on the paramacular area of the left eye surrounded by diffuse atrophy (Figure 1A <ImgLink imgNo="1" imgType="figure"/>). Feeding vessel or retinal detachment was not observed. Grade 1 hypertensive retinopathy was present in both eyes. Fundus autofluo<TextGroup><PlainText>re</PlainText></TextGroup>scence showed a wide hypoautofluorescent area due to the diffuse RPE atrophy with regular borders and hyperautofluorescence along the margin of the pigmented lesion (Figure 1B <ImgLink imgNo="1" imgType="figure"/>). B-scan ultrasonography disclosed a preretinal hyperechoic lesion with posterior shadowing (Figure 2A <ImgLink imgNo="2" imgType="figure"/>). Optical coherence tomography (OCT) showed the preretinal localization of the foreign body with posterior shadowing (Figure 2B <ImgLink imgNo="2" imgType="figure"/>). Neither USG nor OCT showed any choroidal mass (Figure 2 <ImgLink imgNo="2" imgType="figure"/>). When questioned in detail, it was revealed that the patient had been hit by an iron fragment in the left eye forty years ago.</Pgraph></TextBlock> <TextBlock linked="yes" name="Discussion"> <MainHeadline>Discussion</MainHeadline><Pgraph>Pseudomelanoma management can be challenging, and misdiagnosis may lead to severe therapeutic consequences. Cases of misdiagnosis which led to enucleation are reported in the literature <TextLink reference="3"></TextLink>, <TextLink reference="4"></TextLink>. Different studies report various frequencies for pseudomelanoma diagnosis, possibly due to variable primary ophthalmic care conditions. In a retrospective analysis of 12,000 patients referred for choroidal melanoma, the frequency of pseudomelanoma was reported as 14.4% by Shields et al. <TextLink reference="2"></TextLink>. Another study revealed a pseudomelanoma frequency of 53.7% (246/458) among eyes examined for choroidal melanoma <TextLink reference="5"></TextLink>.</Pgraph><Pgraph>The most common conditions that mimick choroidal melanoma are choroidal nevus, peripheral exudative hemorrhagic chorioretinopathy, and congenital hypertrophy of retina pigment epithelium (RPE), respectively <TextLink reference="1"></TextLink>. Other conditions include hemorrhagic RPE detachment, massive subretinal hemorrhage due to neovascular age-related macular degeneration, choroidal hemangioma, RPE hyperplasia, choroidal metastasis, vasoproliferative tumors, and intraocular foreign body. The frequency of intraocular foreign body among the reasons of pseudomelanoma diagnosis was only 0.17% <TextLink reference="2"></TextLink>. Cho<TextGroup><PlainText>rio</PlainText></TextGroup>retinal tissue responds to injury by penetration with granulation, scar formation, and proliferation of retinal pigment epithelium <TextLink reference="6"></TextLink>, and therefore the lesion may be mistaken for melanoma.</Pgraph><Pgraph>In the presented case, the patient had a slightly elevated hyperpigmented lesion surrounded by RPE atrophy. No distinguishable foreign body was observed. The fundoscopic image resembled a melanoma, but USG and OCT scans revealed a high reflective foreign body. If the lesion was choroidal melanoma, we would expect low internal reflectivity (acoustic hollowness) on echography. Transillumination had no impact on differential diagnosis because of the posterior location of the lesion. Fluorescein angiography could not be obtained because the patient had chronic renal failure. The role of different diagnostic techniques in the differential diagnosis of melanoma can be seen in Table 1 <ImgLink imgNo="1" imgType="table"/>.</Pgraph></TextBlock> <TextBlock linked="yes" name="Conclusion"> <MainHeadline>Conclusion</MainHeadline><Pgraph>Multimodal imaging can be helpful to make the correct diagnosis. Accurate diagnosis of choroidal melanoma is of utmost importance since the therapeutic choices can have serious side effects, including devastating operations. As projected, due to the novel diagnostic techniques and increased knowledge of mimicking lesions the inci<TextGroup><PlainText>dence</PlainText></TextGroup> of misdiagnosis decreased. Antecedent history of penetrating ocular trauma should prompt the surgeon to re-evaluate a diagnosis of melanoma.</Pgraph></TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Authors’ ORCIDs</SubHeadline><Pgraph><UnorderedList><ListItem level="1">Aslıhan Yılmaz Çebi: <Hyperlink href="https://orcid.org/0000-0001-7919-9099">0000-0001-7919-9099</Hyperlink></ListItem><ListItem level="1">Bilge Batu Oto: <Hyperlink href="https://orcid.org/0000-0002-9729-2577">0000-0002-9729-2577</Hyperlink></ListItem><ListItem level="1">Oğuzhan Kılıçarslan: <Hyperlink href="https://orcid.org/0000-0003-4061-2047">0000-0003-4061-2047</Hyperlink></ListItem><ListItem level="1">Ahmet Murat Sarıcı: <Hyperlink href="https://orcid.org/0000-0002-9061-4385">0000-0002-9061-4385</Hyperlink></ListItem></UnorderedList></Pgraph><SubHeadline>Ethics statement</SubHeadline><Pgraph>This study was performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from the patient.</Pgraph><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Shields CL</RefAuthor> <RefAuthor>Manalac J</RefAuthor> <RefAuthor>Das C</RefAuthor> <RefAuthor>Ferguson K</RefAuthor> <RefAuthor>Shields JA</RefAuthor> <RefTitle>Choroidal melanoma: clinical features, classification, and top 10 pseudomelanomas</RefTitle> <RefYear>2014</RefYear> <RefJournal>Curr Opin Ophthalmol</RefJournal> <RefPage>177-85</RefPage> <RefTotal>Shields CL, Manalac J, Das C, Ferguson K, Shields JA. Choroidal melanoma: clinical features, classification, and top 10 pseudomelanomas. Curr Opin Ophthalmol. 2014 May;25(3):177-85. DOI: 10.1097/ICU.0000000000000041</RefTotal> <RefLink>https://doi.org/10.1097/ICU.0000000000000041</RefLink> </Reference> <Reference refNo="2"> <RefAuthor>Shields JA</RefAuthor> <RefAuthor>Mashayekhi A</RefAuthor> <RefAuthor>Ra S</RefAuthor> <RefAuthor>Shields CL</RefAuthor> <RefTitle>Pseudomelanomas of the posterior uveal tract: the 2006 Taylor R. Smith Lecture</RefTitle> <RefYear>2005</RefYear> <RefJournal>Retina</RefJournal> <RefPage>767-71</RefPage> <RefTotal>Shields JA, Mashayekhi A, Ra S, Shields CL. Pseudomelanomas of the posterior uveal tract: the 2006 Taylor R. Smith Lecture. Retina. 2005 Sep;25(6):767-71. DOI: 10.1097/00006982-200509000-00013</RefTotal> <RefLink>https://doi.org/10.1097/00006982-200509000-00013</RefLink> </Reference> <Reference refNo="3"> <RefAuthor>Lipper S</RefAuthor> <RefAuthor>Eifrig DE</RefAuthor> <RefAuthor>Peiffer RL</RefAuthor> <RefAuthor>Bagnell CR</RefAuthor> <RefTitle>Chorioretinal foreign body simulating malignant melanoma</RefTitle> <RefYear>1981</RefYear> <RefJournal>Am J Ophthalmol</RefJournal> <RefPage>202-5</RefPage> <RefTotal>Lipper S, Eifrig DE, Peiffer RL, Bagnell CR. Chorioretinal foreign body simulating malignant melanoma. Am J Ophthalmol. 1981 Aug;92(2):202-5. DOI: 10.1016/0002-9394(81)90771-6</RefTotal> <RefLink>https://doi.org/10.1016/0002-9394(81)90771-6</RefLink> </Reference> <Reference refNo="4"> <RefAuthor>Lang GK</RefAuthor> <RefAuthor>Völcker HE</RefAuthor> <RefAuthor>Naumann GO</RefAuthor> <RefTitle>Strikt fokale Siderosis bulbi posterior</RefTitle> <RefYear>1987</RefYear> <RefJournal>Klin Monbl Augenheilkd</RefJournal> <RefPage>137-9</RefPage> <RefTotal>Lang GK, Völcker HE, Naumann GO. Strikt fokale Siderosis bulbi posterior [Strictly focal siderosis bulbi posterior]. Klin Monbl Augenheilkd. 1987 Aug;191(2):137-9. DOI: 10.1055/s-2008-1050483</RefTotal> <RefLink>https://doi.org/10.1055/s-2008-1050483</RefLink> </Reference> <Reference refNo="5"> <RefAuthor>Stoffelns BM</RefAuthor> <RefAuthor>Schöpfer K</RefAuthor> <RefAuthor>Kramann C</RefAuthor> <RefTitle>Pseudomelanome der Aderhaut</RefTitle> <RefYear>2007</RefYear> <RefJournal>Klin Monbl Augenheilkd</RefJournal> <RefPage>274-8</RefPage> <RefTotal>Stoffelns BM, Schöpfer K, Kramann C. Pseudomelanome der Aderhaut [Pseudomelanomas of the choroid]. Klin Monbl Augenheilkd. 2007 Apr;224(4):274-8. DOI: 10.1055/s-2006-927399</RefTotal> <RefLink>https://doi.org/10.1055/s-2006-927399</RefLink> </Reference> <Reference refNo="6"> <RefAuthor>Lebowitz HA</RefAuthor> <RefAuthor>Couch JM</RefAuthor> <RefAuthor>Thompson JT</RefAuthor> <RefAuthor>Shields JA</RefAuthor> <RefTitle>Occult foreign body simulating a choroidal melanoma with extrascleral extension</RefTitle> <RefYear>1988</RefYear> <RefJournal>Retina</RefJournal> <RefPage>141-4</RefPage> <RefTotal>Lebowitz HA, Couch JM, Thompson JT, Shields JA. Occult foreign body simulating a choroidal melanoma with extrascleral extension. Retina. 1988;8(2):141-4. DOI: 10.1097/00006982-198808020-00011</RefTotal> <RefLink>https://doi.org/10.1097/00006982-198808020-00011</RefLink> </Reference> </References> <Media> <Tables> <Table format="png"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Table 1: Different diagnostic techniques and their role in the diagnosis and/or management of choroidal melanoma</Mark1></Pgraph></Caption> </Table> <NoOfTables>1</NoOfTables> </Tables> <Figures> <Figure format="png" height="496" width="1058"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Figure 1: A. Fundus image shows pigmented and elevated lesion on the paramacular area, surrounded by diffuse atrophy. B. Fundus autofluorescence image shows a wide hypoautofluorescent area due to the RPE atrophy with regular borders and hyperautofluorescence along the margin of the lesion.</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="708" width="659"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Figure 2: A. B-scan ultrasonography image shows a preretinal hyperechoic lesion with posterior shadowing. B. Optical coherence tomography image shows the preretinal localization of the foreign body with posterior shadowing. Both images do not disclose any choroidal mass.</Mark1></Pgraph></Caption> </Figure> <NoOfPictures>2</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>