Maniwan JMM, J Ophthalmic Clin Res 2021, 8: 079

DOI: 10.24966/OCR-8887/100079

HSOA Journal of
Ophthalmology & Clinical Research
Case Report

Case Presentation
Epithelioid Choroidal A 49-year-old male visited the Rizal Medical Center outpatient
Melanoma in a Middle-Aged department with a chief complaint of proptosis of the left eye. He had
Filipino: A Case Report an eight-month history of gradual blurring of vision of the left eye
accompanied by eye pain, and left-sided headache which prompted
consult with assessment of cataract. During the interim, there was loss
Jo Michael M Maniwan1*, Eric Valera2 and Andrei Martin3 of vision, eye redness and gradual proptosis of the left eye. These
ocular symptoms were accompanied by weight loss and occasional
1
Ophthalmology Resident, Rizal Medical Center, Philippines
body malaise. He had unremarkable past medical, past ocular, family
2
Consultant, Ophthalmoic Pathologist, Rizal Medical Center, Philippines and personal history. Ocular examination of the left eye showed no
3
Consultant, Ocular Oncologist, Rizal Medical Center, Philippines
light perception, and a visual acuity of 20/20 on the right eye. On
gross examination, there was gross proptosis on the left eye with
resistance on retropulsion and absence of bruits with severe chemosis
(Figure 1). Anterior segment examination showed an opacified cornea
Abstract
with diffuse uptake, shallow anterior chamber with no view of the
Background: To present a case of choroidal melanoma in a 49-year- lens. Examination of the right eye was unremarkable.
old male patient.
Case Presentation: A 49-year-old male presented with an eight-
month history of gradual blurring of vision of the left eye accompanied
by eye pain, left-sided headache, eye redness, gradual proptosis
and opacification of the cornea. Ocular ultrasound revealed a
homogenous echodensities with moderate echogenicity and
intermittent loculation occupying the whole vitreous cavity. Chest CT-
scan with contrast showed multiple nodules on both lung fields evident
of metastasis. The patient was lost to follow and sought consult 1
year after presenting with a 5x4.8cm grapelike mass with discharge
and occasional bleeding, resistance on retropulsion. Incision biopsy
was done and revealed epithelioid pigmented melanocytes with
enlarged pleomorphic nuclei and prominent nucleoli.
Keywords: Choroid; Malignancy; Melanoma

Background Figure 1: Clinical photograph of the left eye with gross proptosis, chemosis and
opacification of cornea.
Ocular Melanomas are the second most common type of melanoma
after cutaneous. It arises from melanocytes situated in conjunctival
membrane and uveal tract of the eye [1]. Uveal melanomas A B-scan ultrasound of the left eye revealed homogenous
encompass the iris, ciliary body and the choroid. In the Philippines, echodensities with moderate echogenicity and intermittent loculation
uveal melanoma is the second most common intraocular malignant occupying the whole vitreous cavity (Figure 2) with an impression of
tumor which accounts for 8% of all intraocular malignancies [2]. an intraocular mass with a plan to do enucleation of the left eye.
Choroidal melanomas are more frequent to occur in comparison to
iris and ciliary body melanomas [3,4]. We present a case of choroidal
melanoma in a 49-year-old Filipino who presented with an eight
months history of gradual blurring of vision, eye pain and progressive
proptosis with evidence of metastasis.
*Corresponding author: Jo Michael M Maniwan, Ophthalmology Resident,
Rizal Medical Center, Philippines, E-mail: [email protected]
Citation: Maniwan JMM, Valera E, Martin A (2021) Epithelioid Choroidal
Melanoma in a Middle-Aged Filipino: A Case Report. J Ophthalmic Clin Res
8: 079.
Received: April 08, 2021; Accepted: April 12, 2021; Published: April 19, 2021
Figure 2: B-scan ultrasound of the left eye with homogenous echodensities with
Copyright: © 2021 Maniwan JMM, et al. This is an open-access article distribut- moderate echogenicity and intermittent loculation occupying the whole vitreous
ed under the terms of the Creative Commons Attribution License, which permits cavity.
unrestricted use, distribution, and reproduction in any medium, provided the orig-
inal author and source are credited.
Citation: Maniwan JMM, Valera E, Martin A (2021) Epithelioid Choroidal Melanoma in a Middle-Aged Filipino: A Case Report. J Ophthalmic Clin Res 8: 079.

• Page 2 of 4 •

Chest CT-scan with contrast revealed multiple subcentimeter

pulmonary nodules in both lungs with a consideration of a metastatic
process (Figure 3). Abdominal CT-scan with contrast, however, did
not reveal nodules, masses or lymphadenopathy. The patient was
referred to oncology for metastatic work-up and palliative care but
he was lost to follow-up and noted significant increase in proptosis
and outgrowth of the intraocular mass which prompted consult after
one year. Gross examination of the left eye revealed a 5×4.8cm
grapelike mass with discharge and occasional bleeding, resistance
on retropulsion (Figure 4). Visual acuity of the right eye was 20/20
with unremarkable ocular examination of the anterior and posterior
segment. Incision biopsy was performed getting 3 tissues from the
mass, adjacent conjunctivae and skin.
Figure 5: High power objective (original magnification x 40) of ocular mass
tissue. A) Epithelioid pigmented melanocytes with enlarged pleomorphic nuclei
and prominent nucleoli (encircled in red); B) Necrotic debris (blue arrow) and
degenerated cells with cytoplasmic melanin (yellow arrow).

Figure 3: Chest CT-scan with multiple non-enhancing subcentimeter nodules

seen in the right upper and middle lobe, and in the apical segment of the left Figure 6: Low power objective (original magnification x 10) of A) adjacent
upper lobe (encircled in yellow). conjunctivae with Conjunctival hemorrhage and thrombosis (blue arrow) and
subepithelial inflammation (yellow arrow); and, B) adjacent skin with normal
epidermis and subcutaneous tissue.

Discussion
Uveal melanomas are highly malignant epithelial cancers [5]
which tend to commonly arise during the 5th to 6th decade wherein
65% of patient is over the age of 50 years. Risk factors include:
light eye color, fair skin, Caucasians of Northern European descent,
UV radiation exposure, xeroderma pigmentosum, and oculodermal
melanocytosis [4]. Patients remain asymptomatic until the tumour
has grown sufficiently to become necrotic and produce complications
such as endophthalmitis, massive intraocular hemorrhage, and/or
secondary glaucoma. Choroidal melanoma usually presents with
blurring of vision, painless and progressive visual field loss as the
Figure 4: Clinical photograph of the left eye (1 year after) with a 5×4.8cm hy- peripheral melanoma enlarges, floaters, and flashes of light in cases
perpigmented grapelike mass with discharge and bleeding. of necrosis of tumor or hemorrhage in the adjoining areas [3]. The
choroid being devoid of lymphatics hence majority of the choroidal
melanomas spread by hematogenous route mainly to the liver and
The pathologic examination using hematoxylin-eosin stain lungs [6].
showed epithelioid pigment melanocytes with enlarged pleomorphic
nuclei and prominent nucleoli (Figure 5A) and necrotic debris with The modified Callendar’s classification of uveal melanoma
degenerated cells with cytoplasmic melanin (Figure 5B). Adjacent has five categories: 1) Spindle A cell type tumors comprise 5% of
conjunctivae revealed evidence of chronic conjunctivitis (Figure 6A) all choroidal melanomas, 2) Spindle B & fascicular comprise 39%,
while the skin was otherwise normal (Figure 6B). The patient was 3) Pure epithelioid cell melanomas comprise 3%, 4) Mixed cell
referred back to oncology for management and palliative care. melanoma (combination of spindle and epithelioid types) comprise

Volume 8 • Issue 1 • 100079

J Ophthalmic Clin Res ISSN: 2378-8887, Open Access Journal
DOI: 10.24966/OCR-8887/100079
Citation: Maniwan JMM, Valera E, Martin A (2021) Epithelioid Choroidal Melanoma in a Middle-Aged Filipino: A Case Report. J Ophthalmic Clin Res 8: 079.

• Page 3 of 4 •

45% and 5) Necrotic cell type comprise 7% [7]. Among the five types, 2. Domingo RED, Manganip LE, Castro RM (2015) Tumors of the eye and
the epithelioid cell type has the lowest survival rate at 28%. ocular adnexa at the Philippine Eye Research Institute: a 10-year review.
Clin Ophthalmol 9: 1239-1247.
Conclusion
3. Shukla S, Acharya S, Dulani M (2015) Choroid Melanoma - A Rare Case
Pure epithelioid cell choroidal melanoma is the rarest among Report. J Clin Diagn Res 9: ED09-ED10.
the cell types and has the worst prognoses which correspond to the 4. Krantz BA, Dave N, Komatsubara KM, Marr BP, Carvajal RD (2017)
histopathologic findings of our patient. Early detection is ideal but Uveal melanoma: epidemiology, etiology, and treatment of primary dis-
would pose a challenge due to its asymptomatic presentation during ease. Clin Ophthalmol 11: 279-289.
the early course of the disease and symptoms that mimics other 5. Font RL, Spaulding AG, Zimmerman LE (1968) Diffuse malignant mela-
ocular diseases. Complete ophthalmologic examination and high noma of the uveal tract. A clinicopathologic report of 54 cases. Trans Am
degree of suspicion combined with ocular and systemic imaging Acad Ophthalmol Otolaryngol 72: 877-895.
would help patients with this pathology. In the current scenario, 6. Kath R, Hayungs J, Bornfeld N, Sauerwein W, Hoffken K, et al. (1993)
treatment is preferably palliative and tailored toward the patient’s Prognosis and treatment of disseminated uveal melanoma. Cancer 72:
symptomatology. 2219-2223.

7. McLean IW, Zimmerman LE, Evans RM (1996) Reappraisal of Callen-

References der’s spindle A type of malignant melanoma of choroid and ciliary body.
Am J Ophthalmol 86: 557-564.
1. Jovanović P, Mihajlovic M, Djordjevic-Jocic J, Vlajković S, Cekić S, et al.
(2013) Ocular melanoma: An overview of the current status. Int J Clin Exp
Pathol 6: 1230-1244.

Volume 8 • Issue 1 • 100079

J Ophthalmic Clin Res ISSN: 2378-8887, Open Access Journal
DOI: 10.24966/OCR-8887/100079
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