Three Suspect Choroidal Melanomas Cases In Consecutive Weekends On-Call

We report three cases of suspect choroidal melanomas in consecutive weekends on call. These were seen by the ophthalmology resident on call at a district general hospital and referred to a tertiary center with an ocular oncology service.

Case 1 – A 63-year old male presented with a six-week history of left eye flashing lights. There was an amelanotic, mushroom-shaped, choroidal lesion measuring 11.7 x 9.7 x 8mm in the inferotemporal quadrant of the left eye with subretinal fluid and overlying lipofuscin, with low to medium echogenicity on B-scan. MOLES score was 6. This was found to be an amelonatic choroidal melanoma (TNM cT2a, Stage IIa) and he had proton beam radiotherapy of 52 grays in 4 fractions given over 4 days.

Case 2 – A 30-year old male presented with left eye floaters for four weeks. He had an atypical juxtapapillary, choroidal lesion measuring 4.4 x 4.4 x 3.8mm with very low echogenicity on B-scan and possible extrascleral extension. MOLES score was 4. Due to the relatively shallow thickness of the lesion and characteristics on multimodal imaging, this lesion was deemed to be an indeterminate melanocytic choroidal mass. MDT consensus advised continued monitoring.

Case 3 – A 75-year-old lady presented with right eye floaters and an inferotemporal visual field defect for two months. Past ophthalmic history included a vitrectomy, epiretinal membrane peel and cataract surgery in the eye many years ago. There was a large, mushroom-shaped, choroidal lesion with enlargement compared to previous fundal photo, subretinal fluid and low to medium echogenicity on B-scan. MOLES score was 8. The patient did not attend her ocular oncology appointment and unfortunately passed away shortly after.

These cases highlight the importance of the MOLES score and multimodal imaging for choroidal melanomas. Management takes into account tumour size, extrascleral extension, imaging characteristics and patient preferences. One case highlighted the challenge of indeterminate lesions, where urgent treatment may not always be warranted, and serial imaging and long-term surveillance may be more favourable.