A RARE CASE OF CHOROIDAL HAEMORRHAGE MIMICKING CHOROIDAL MELANOMA Dr. Sachi M. Manache Post Graduate Resident Pravara Institute of Medical Sciences, Loni

Introduction Choroidal melanoma is the most common primary intra-ocular malignant tumor in adults and second most common site of melanomas in the body(1). Current diagnosis of choroidal melanoma is based on both the clinical appearance and modern diagnostic techniques such as indirect ophthalmoscopy, A- and B- ultrasonography scans, fundus fluorescein angiography(2). Choroidal hemorrhage is usually seen as expulsive hemorrhage that is related to surgical complications, or to either a perforating or blunt eye injury. This type of hemorrhage is quite rare in the absence of surgery or trauma(3).

Case Report A 75 year old female presented to the OPD with pain in the left eye since 6 months. She had no perception of light in the left eye since childhood. There was no obvious history of trauma or surgery in the left eye. She was a known case of type II diabetes and hypertension on regular medication since 1 year. General and systemic examination was normal. BCVA of right eye was 6/18 and that of left eye was no PL. Anterior segment and fundus examination of right eye was normal except for early cataractous changes.

Anterior segment examination of left eye Case Report Anterior segment examination of left eye Digitally, intraocular pressure was found to be markedly raised. Circumcorneal and Conjunctival congestion was present. Cornea was opaque with superficial and deep vascularisation all over the cornea. Cornea showed a white circular fungating mass of 3 mm diameter in its centre. Rest of the details of the anterior segment were not appreciated.

Case Report B- scan of left eye revealed: A 23×8 mm size, well defined, oval shaped hyper-reflective, solid natured, lobulated mass arising from the choroid on the nasal aspect and protruding into the vitreous cavity. Choroidal excavation was noted. It showed peripheral vascularity on colour doppler.

Case Report Fundus examination and fundus fluorescein angiography could not be done due to opaque cornea. Ultrasound abdomen and chest x-ray were normal. B-scan findings and colour doppler were suggestive of vascular neoplastic mass. Keeping age of the patient in mind, a choroidal melanoma was suspected. Since there was no PL in the left eye, enucleation was planned.

Case Report Enucleation of the eyeball was performed and it showed bluish appearance of the sclera due to underlying mass. There were no areas of scleral extension. Sagittal cut section of the eyeball revealed a black mass on its nasal aspect measuring 1×0.5 cm with a cyst with protrusion into the vitreous cavity.

Case Report However histopathology showed presence of haemorrhage at 2 foci with no evidence of malignant cells. The haemorrhage was organised and showed fibroblasts and neovascularisation At these places, retina was seen to be detached from choroid. Cornea was lined by non keratinised stratified squamous epithelium which showed ulceration with infiltration with acute inflammatory cells, predominantly neutrophils.

Discussion Choroidal haemorrhage is usually seen as expulsive haemorrhage related to surgical invasion and is rarely observed in the absence of surgery or trauma(3). The risk factors for expulsive haemorrhage include ocular risk factors (high myopia, past history of ocular injury, glaucoma etc.) and general risk factors (hypertension, arteriosclerosis, diabetes, blood clotting abnormalities etc.)(3). Choroidal melanoma is the most common primary, unilateral intra-ocular tumour arising from the pigment cells of choroid(4). It is common between the age group of 40-60 years(4). It is usually pigmented but is occasionally nonpigmented(4).

Discussion By B-scan classic features of choroidal melanoma are: An oval shaped or mushroom shaped mass protruding in the vitreous cavity, acoustically silent zone within the melanoma, choroidal excavation and shadowing in the orbit(2). In this case, ultrasound B-scan was the only investigation guiding towards the treatment. B-scan images were mimicking those seen a choroidal melanoma. Since the patient had a painful blind eye and according to the clinical presentation and B-scan findings, enucleation was performed. However final diagnosis was arrived at only after histopathology reports as choroidal haemorrhage .

Conclusion In deficiency of complete investigations, absence of pre-existing cause and clinical presentation, a choroidal haemorrhage can mimic choroidal melanoma in rare cases. Hence while suspecting a case of choroidal melanoma, alternative diagnosis of choroidal haemorrhage should be considered.

References Albert DM. Principles and Practice of Ophthalmology. In: Albert, Jakobiec, editors. Philadelphia, PA: W.B. Saunders Co; Ch. 258. 1994:3197–8. Parul S, Abhishek S. Choroidal melanoma.Oman J Ophthalmol. 2012. Jan-Apr; 5(1): 3–9. Takekida S, Watanabe H, Tsukahara Y : A case of spontaneous retinochoroidal hemorrhage with idiopathic Hypertension. Folia Ophthalmol Jpn 52 : 59- 62, 2001. Ramanjit S., Radhika T. Parson’s Diseases of the Eye, 20th Edition. pg. 354-57.