A 72-year-old woman was referred for a cataract consultation. The patient reported a gradual blurring of the vision in her right eye for the past year that noticeably deteriorated over the last 6 months. She now has difficulty reading the newspaper and seeing the captions on TV despite a recent update of her glasses prescription. Her past ocular history was unremarkable. Past medical history was notable for hypertension, arthritis, and COPD, all controlled with medication.
Her BSCVA was 20/60 OD and 20/20 OS. Pupillary response, extraocular motility, and confrontation visual fields were all normal. IOP measured 18 mm Hg OU. Anterior segment exam revealed a moderate nuclear sclerotic and cortical spoking cataract OD and an early nuclear sclerotic cataract OS. This was the slit lamp appearance of the right eye:
A prominent conjunctival vessel was visible inferonasally, and the lens opacity was more prominent in that quadrant. Retroillumination of the lens showed a dark area from the 2:30 to 5:30 o’clock position. Upon further questioning, the patient noticed the large blood vessel for approximately one year.
Direct illumination at the slit lamp revealed a vascular retrolental mass:
The optic nerve and macula appeared normal. The patient was referred to a tumor specialist for further evaluation and treatment of a presumed ciliary body/choroidal melanoma.
Followup: Examination by the tumor specialist 3 days later confirmed a large ciliochoroidal melanoma approximately 14 x 8 x 10.5 mm in size extending posteriorly to the equator. There was no subretinal fluid or orange pigment. Gonioscopy showed some increased pigmentation of the angle in that area but no evident invasion or neovascularization. The patient was taken to the OR and fine-needle aspiration biopsy was performed. Cytology revealed a mixed cell (spindle and epithelioid) melanoma. The tumor was localized in preparation for proton radiation.
Discussion: This case of a ciliochoroidal melanoma presenting with a cataract underscores the importance of a careful preoperative examination including a dilated retinal exam. This patient demonstrated a sentinel vessel and segmental cataract, which are associated with such tumors. Prompt referral to an ophthalmologist specializing in ocular tumors is necessary so that the patient can be counseled and treated without delay. Treatment options include radiation therapy, eye wall resection, or enucleation.