This document discusses choroidal nevus and melanoma. It begins by introducing choroidal melanocytes and describing the differences between benign nevi and malignant melanomas. It then discusses choroidal nevi in more detail, including their prevalence, appearance on examination, investigation methods, and recommended follow up. The document also provides extensive details on choroidal melanoma, including risk factors, pathology, clinical presentation, location, investigation, differential diagnosis, metastasis patterns, treatment options, and prognosis.

1. CHOROIDAL NEVUS & MELANOMA
Amara Yousef

2. INTRODUCTION
 Melanocytic tumors of the UVEA
 Choroidal melanocytes.
 Mesodermal tissue
 Typically disseminate hematogenously.
 Benign NEVI
 Malign Melanomas

3. NEVUS OF THE CHOROID
 10% of the population.
 Caucasians
 Associated with NF 1 and dysplastic nevus
syndrome
 Growth in pre-pubertal years
 Histology: spindle cells melanocytes

4. NEVUS OF THE CHOROID
 No clinical symptoms
 incidental finding
 visual field defects
 Ophthalmoscopy:
 flat or minimally elevated
 pigmented (gray-brown)
 Distinct/indistinct margins?
 Some nevi are amelanotic.

6. NEVUS OF THE CHOROID
 <10mm basal diameter
 <1mm thickness
 RPE disturbance
 Drusen,
 Serous detachment,
 Choroidal neovascular
membranes

7. INVESTIGATION
 Photography

8. INVESTIGATION
 US
• Flat
• High internal reflectivity

9.  FA?

10. ATYPICAL NEVUS
 Amelanotic

11.  Halo Nevus surrounded by a pale zone

12. SUSPICIOUS NEVUS
 Documented growth
 Symptoms: blurred vision, metamorphopsia,
VF loss, photopsia
 larger size at presentation
 >5mm diameter
 >1mm thickness
 Absence of drusen or RPE changes
 Associated sub-retinal fluid
 Presence of orange pigmentation
 Margin near optic disc

13. RECOMMENDED FOLLOW-UP
 NO suspicious features:
 require no treatment.
 first year, monitored twice;
 evaluated annually
 sunglasses.
 Suspicious features :
 Evaluated experienced center
 possible treatment
 four to six months

14. CHOROIDAL MELANOMA
 The most common primary intraocular
malignancies in adults.
 In the USA 6-7/million/year
 50s - 60s
 slight male predominance
 5% of all melanomas
 Extremely rare in children.
 White individuals (northern Europe)

15. RISK FACTORS
Oculodermal melanocytosis

16. PATHOLOGY
3 cell types:
1. Spindle cell type A
2. Spindle cell type B
3. Epitheliod cell
Pathologic classification:
1. Spindle cell melanomas good prognosis
2. Epithelioid cell melanomas intermidiate
3. Mixed cell melanomas Poorest survival
prognoses

18. CLINICAL PRESENTATION:
Frequently asymptomatic
 Blurred vision, scotoma, flashing lights, floaters
 visual field loss
 Retinal detachment.
 Hemorrhage with arterial erosion.
 Pain
 glaucoma
Anamnesis

19. ON EXAM
 Solitary Pigmented, elevated, dome-shaped subretinal
mass.
 Amelanotic - dark brown
 Indiscrete margins
 Irregular configuration
 Rarely diffuse extensive flat tumor
 Clumps of orange pigment
 Collar stud if broke through Bruch’s
 Exudative retinal detachment
 Choroidal folds
 Intraocular inflammation
 Hemorrhage

22. LOCATION
1- Temporaly hemisphere - posterior to equator
“most common location”
2- Posterior Uvea
 Choroidal lesions (85%)
 Ciliary body (10%)
3- Anterior Uvea
 Iris lesions (5%): Within previous chambler.

23. INVESTIGATION
 FA: differentiate from hemangioma
 US: Dimentions, extraocular spread, collar stud
(pathognomonic), choroidal excavation, high
surface and low internal reflectivity
 Dopller to differentiate from blood
 CT, MRI: Invasion, optic nerve involvment,
metastasis?
 Biopsy in uncertain cases (FNA or vitrectomy)

24. Low internal reflectivity

25. 1.Choroidal nevi
2. Choroidal metastases.
3. Choroidal hemangioma (hamartoma)
 Benign vascular lesion
 Circumscribed form in adults, sometimes with retinal
detachment.
 Diffuse form in infants associated with Sturge -Weber.
 Increased T2 signal and enhancement than melanoma.
4. Retinal Detachment
 Serous, exudative or haemorrhagic.
 Myriad etiologies, including trauma, inflammation,
underlying tumor, or systemic disease.
 Does not enhance, but may obscure underlying mass.
DIFFERENTIAL DIAGNOSIS

26. 5. Choroidal osteoma
 Tendency to occur in young adult women.
 Often asymptomatic , found incidentally.
 Curved, plaque-like Ca++ lesion along posterior globe.
6. Idiopathic inflammatory pseudotumor
 It can affect any orbital structure (Globe/scleral
involvement # endophthalmitis).
 Painful, inflammatory presentation.
 Granulomatous disease (sarcoidosis) and autoimmune
diseases may appear similar.
7. Retinoblastoma
• Most common intraocular tumor in children. • Rarely
occurs in adults. • Calcification in 95%.
8. Deciform macular and extramacular lesions
DIFFERENTIAL DIAGNOSIS

27. METASTASIS
COLLABORATIVE OCULAR MELANOMA STUDY (COMS)
 At initial presentation < 2% of patients.
 25% at 5 years after initial treatment
 34% at 10 years after treatment
 50% at 25 years after treatmen
 liver involvement 90% of patients
 lung involvement 25%
 bone involvement in nearly 20%
 skin and subcutaneous tissue 10%

28. CLINICAL EVALUATION OF METASTATIC UVEAL
MELANOMA
 liver imaging-ultrasonography in routine evaluation
 liver function tests
 Chest x-ray
If any of the above are abnormal:
 Triphasic liver CT
 CT-PET of the abdomenl/chest
 MRI of the abdomen/chest

29. TREATMENT
 Size, location, and extent of the tumor
 visual status of the affected eye and of the
fellow eye
 age and general health of the patient

30. Observation
TREATMENT

31. BRACHYTHERAPY
RADIOACTIVE PLAQUE)
Localalization of the tumor,
transparent or metal ring
sutured to the sclera
 Base less than 20 mm
 Good chance for salvaging vision
 Ruthinium 106 (up to 5mm thickness) or Iodine 125 (up to 10
mm thickness)
 Transpupillary thermotherapy
 Removed after 3-7 days (80 gray to apex)
 tumor starts to regress 1-2 months later, continues for years
 Pigmented scar, cataract, radiation retinopathy, optic neuropathy,
CME.

32. EXTERNAL PROTON BEAM RADIATION
 Ineffective as a single-modality treatment
 High dose in tumor, low dose on tissues
 Indications: large tumors, posterior tumors
 Tumor regression is slow
 Complications: cataract, retinopathy…
 Also: loss of lashes, depigmentation of lid skin…

33. TRANS SCLERAL CHOROIDECTOMY
 Rarely performed
 Very thick tumors (base less than 16mm)
 Complications: Retinal Detachment

34. TRANS PUPILLARY THERMOTHERAPY
 Infrared laser beam
 Tumor cell death by hyperthermia
 Usually adjunct to brachytherapy or for small
pigmented tumors
 For people with short life expectation, severely
debilitated

35. ENUCLEATION
 large tumor size
 Optic disc invasion
 Extensive involvement of the ciliary body or angle.
 Irreversible loss of useful vision
 Technique: complete removal of eye ball, implant
 Rarely recurrence of tumor

38. ARAD - Romania