History of present illness
A 58-year-old female patient was referred for evaluation of a choroidal mass in the right eye.
Ocular examination and imaging
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Best corrected visual acuity was 20/20 in both eyes.
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Pupils, intraocular pressure, and extraocular motility were all within normal limits.
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External and slit-lamp examination were unremarkable aside from minimal nuclear sclerotic cataracts bilaterally.
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Dilated fundus examination demonstrated mildly pigmented elevations overlying the inferotemporal vortex vein in the right eye ( Fig. 44.1 ). There was no evidence of hemorrhage, subretinal fluid, orange pigment, or other associated pathology. The left eye was unremarkable.
Fig. 44.1
Montage of color fundus photographs demonstrating a pigmented mass (arrow) overlying the inferotemporal vortex vein but an otherwise normal retina.
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B-scan ultrasonography demonstrated enlargement of the lesion with Valsalva and downgaze and flattening of the lesion with ocular digital pressure and primary gaze ( Fig. 44.2 ).
Fig. 44.2
Dynamic B-scan ultrasonography showing that the lesion (arrow) is elevated on downgaze (left) and flattened in primary gaze (right).
Questions to ask
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Any growth of the lesions over time? Malignant neoplasms will grow over time, but benign lesions such as varix of the vortex vein ampulla, choroidal nevi, and congenital hypertrophy of the retinal pigment epithelium are expected to be stable.
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No
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Any history of metastatic cancer? Cancer can metastasize to the choroid causing multifocal tumors.
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No
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Any photopsias or change in subjective vision? Some choroidal melanomas may be symptomatic.
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No
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Any history of retinal bleeds and peripheral drusen? Subretinal hemorrhage from choroidal neovascularization in eyes with peripheral exudative hemorrhagic chorioretinopathy (PEHCR) can be mistaken for a choroidal mass. This would be expected to change color from red to yellow as the hemorrhage dehemoglobinizes over a few of months.
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No
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Assessment
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This is a 58-year-old female patient with one incidentally noted, stable-appearing, mildly pigmented mass overlying the vortex vein in the right eye.
Differential diagnosis
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Varix of the vortex vein ampulla
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Choroidal nevus
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Choroidal metastasis
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Choroidal melanoma
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Peripheral exudative hemorrhagic chorioretinopathy (PEHCR)
Working diagnosis
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Varix of the vortex vein ampulla
Multimodal testing and results
Additional testing is optional and supportive of the clinical diagnosis.
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Dynamic B-scan ultrasonography
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The mass will enlarge with Valsalva or altered change in gaze and diminish with ocular digital pressure.
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Color fundus photographs
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Fundus photography shows the mass(es) overlying the vortex vein with a contiguous mildly pigmented reddish coloration. The mass may have a bilobed appearance. There may be multiple varices.
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Fluorescein angiography and indocyanine green angiography
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Angiography demonstrates the lesion to fill in the early choroidal phase and outlines the lesion as dilations of the vortex vein ampullae that collapse with digital pressure. ,
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Peripheral optical coherence tomography (OCT)
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Peripheral OCT demonstrates a hyporeflective choroidal elevation and dilated choroidal vessels. , No delineated choroidal mass, overlying outer retinal or retinal pigment epithelial changes, or subretinal fluid would be expected. The lesion should diminish with ocular digital pressure.
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Fundus autofluorescence
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The lesions demonstrate a hypoautofluorescent rings surrounding a mildly hyperautofluorescent center.
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Management and follow-up care
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No follow-up (except for routine ocular examinations based on age) or treatment is necessary. Correct diagnosis can save a patient from unnecessary testing and frequent follow-up. ,
Algorithm 44.1 : Algorithm for differential diagnosis
