Abstract
Purpose
To report a clinically challenging case of a choroidal nevus with retinal invasion with accompanying ancillary testing.
Observations
A 60-year-old Caucasian female was referred for a suspicious melanocytic choroidal lesion in her left eye. Ophthalmoscopic examination revealed a melanocytic choroidal lesion, measuring 10 mm × 10 mm in basal diameter. The lesion had a clinically evident area of retinal invasion seen as a protruding choroidal mass at its center, darker in appearance compared to the rest of the lesion, obscuring retinal vessels. The choroidal nevus had associated chronic retinal changes and the absence of overlying orange pigment or subretinal fluid. On fundus autofluorescence, there was a hypoautofluorescent area showing the site of retinal invasion. Fluorescein angiography at the lesion site exhibited central blocked perfusion corresponding to the area of retinal invasion. Ultrasonography showed a dome-shaped choroidal lesion that was optically dense with a medium-high internal reflectivity measuring 3.3mm in thickness. The optical coherence tomography showed a choroidal mass extruding through a break in Bruch’s membrane with inner retinal invasion. A watchful waiting strategy was adopted, and at 28 months follow-up, the choroidal lesion did not show growth or presence of new suspicious features of malignant transformation.
Conclusion and importance
This case highlights the importance of recognizing the key features of choroidal nevi with retinal invasion, which can prevent the treatment of a benign condition and assist in the arrival of a correct diagnosis. These lesions should be monitored for long-term.
1
Introduction
Choroidal nevus is a common intraocular tumor composed of low-grade melanocytes, with a prevalence of 5.6% in Whites, 2.7% in Hispanics, and 0.6% in Blacks. In one large series, choroidal nevi were observed to have a mean thickness and diameter of 1.5mm and 4.9mm, respectively. They need to be monitored due to their potential to cause visual acuity loss and transformation into choroidal melanoma. The annual transformation rate of a choroidal nevus into a choroidal melanoma has been estimated at 1 in 8,845. Approximately less than 1% of choroidal nevi exhibit retinal invasion, and it is a feature more commonly associated to mushroom-shaped choroidal melanoma. We present the case of a 60-year-old Caucasian female with the largest choroidal nevus with retinal invasion yet to be published, focusing on the clinical and imaging characteristics description.
2
Case report/case presentation
A 60-year-old Caucasian female was referred to our ocular oncology center for a suspicious melanocytic choroidal lesion in her left eye (OS). Aside from a history of stage 1 macular hole in her right eye (OD), her ocular and systemic medical history were non-contributory. The best-corrected visual acuity (BCVA) was 20/80 OD and 20/25 OS. The anterior segment examination was unremarkable. Ophthalmoscopic examination was significant for a melanocytic choroidal lesion in the OS, located in the inferonasal periphery measuring 10 mm × 10 mm in basal diameter that was 7mm away from the optic nerve ( Fig. 1 a). The lesion had a clinically evident area of retinal invasion seen as a protruding choroidal mass at the central portion of the lesion. This protruded area had a darker appearance compared to the rest of the lesion, obscuring retinal vessels. There was associated drusen and fibrosis. Overlying orange pigment and subretinal fluid (SRF) were absent. On fundus autofluorescence (FAF) there was a hypoautofluorescent area showing the site of retinal invasion by the choroidal lesion ( Fig. 1 b). Fluorescein angiography (FA) at the lesion site exhibited central blocked perfusion corresponding to the area of retinal invasion ( Fig. 1 c). Ultrasonography (US) showed a dome-shaped choroidal lesion that was optically dense with a medium-high internal reflectivity measuring 3.3mm in thickness ( Fig. 1 d). The optical coherence tomography (OCT) showed a choroidal mass extruding through a break in Bruch’s membrane with inner retinal invasion ( Fig. 1 e). OCT also revealed associated chronic changes such as drusen, retinal pigment epithelium (RPE) hyperplasia, and retinal thinning overlying the choroidal mass. A watchful waiting strategy was adopted, and at 28 months follow-up, the choroidal lesion was stable with no growth or presence of new suspicious features of malignant transformation, confirming our diagnosis of a choroidal nevus with retinal invasion.
