ACUTE ANGLE-CLOSURE ATTACK AS PRIMARY MANIFESTATION OF CHOROIDAL MELANOMA: A CASE REPORT

To report and discuss epidemiological, clinical and therapeutic aspects of a rare case of choroidal melanoma revealed by an acute angle-closure attack.

Mohammed V University, University Hospital Ibn Sina Rabat, Departement A of Ophthalmology, Morocco 

we conducted a full clinical evaluation with ancilliary testing mainly an MRI of the orbit and brain with ocular ultrasonography. we documented the findings by slit-lamp photography and scans.

A 51-years-old male patient presented with a four day history of severe left ocular pain, redness and loss of vision. He denied any previous ocular or systemic illness. Visual acuity in the symptomatic eye was reduced to hand motion with increased ocular pressure estimated at 62mmHG and 360 ° angle closure on goniscopy. Upon biomicroscopic examination, we found diffuse conjunctival injection, perikeratic circle, diffuse corneal edema, shallow central anterior chamber, grade 2 Van Herick, fixed mid-dilated pupil, grade 2 nuclear sclerotic cataract. Funducopic examination revealed a bullous retinal detachment with a kissing configuration with numerous pigmented cells in the vitreal cavity.  Examination of the fellow eye was unremarkable.  B-scan echography showed a Mushroom-shaped hyperechoic lesion originating from the choroid with low internal reflectivity associated with an extensive exsudative retinal detachment with several pinpoint hyperechoic subretinal formations. The same lesion was highlighted by an orbito-cerebral magnetic resonance imaging. A presumptive diagnosis of complicated choroidal melanoma was made. Initial metatatic workup was negative. The acute angle-closure attack was initially managed by intravenous mannitol injection, oral acetazolamide and topical brimonidine and carteol. Lase peripheral iridotomy was avoided. The eye was enucleated 2 days later and showed a spindle B cell melanoma with heavy pigmentation and retinal detachment. There still no evidence of metastasis after 3-years of follow-up.        Several mechanisms may cause ocular hypertension in the presence of uveal melanoma such as invasion or seeding of the angle, iris neovascularization and intraocular hemorrhage. Nevertheless, angle closure due to choroidal melanoma appears a very rare condition. We found rare cases worldwide reporting similar cases of acute  angle-closure attack as primary manifestation of choroidal melanoma.

Clinicians should perform a complete ocular examination to rule out secondary etiologies of angle closure to initiate appropriate management. In presence of media opacities, B-scan echography is mandatory to evaluate an eventual mass formation or membrane detachment. The underlying etiology may be sight-threatening and lifethreatening. Thus, a prompt diagnosis allows instauration of an adapted therapeutic regiment. Laser procedures may be contraindicated in such cases to avoid tumor cell dispersion within the eye.