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Patient Presentation: A 23-year-old obese female was diagnosed with idiopathic intracranial hypertension (IIH) and referred to neurosurgery for ventriculoperitoneal shunt. A baseline ocular examination was performed prior to the procedure.

On examination, vision was 20/200 in the right eye, and 20/40 in the left eye. There was a right relative afferent pupillary defect. Slit lamp examination was normal.

A dilated fundus examination was performed demonstrating the following:

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Ocular Oncology

Case 2

Patient Presentation: A 63-year-old male was referred to a tertiary ophthalmology clinic for assessment of concerning retinal lesions OU. Past medical history was significant for a 10-pack year smoking history. Vision was 20/60 OD and 20/30 OS with no subjective changes over the last 6 months. Optos widefield fundus photos below demonstrated bilateral multifocal choroidal elevated lesions in the posterior pole, most noticeable in the peripapillary region of the right eye and primarily superior to the disc in the left eye.

Fundus autofluorescence was conducted and shown below:

Two areas of hyper-autofluorescence were appreciated: (1) Focal areas of hyper autofluorescence over the lesions (2) Wider and more diffuse hyper autofluorescence around the posterior pole which may be associated with fluid (active or chronic).

OCTs were taken of multiple lesions and are shown below:

Question: What finding is not appreciated in this OCT macula above?

A. Small PED in left image

B. Large area of subretinal fluid in left image

C. Large area of sub-RPE fluid in right image

D. RPE disruption with irregular contour in right image

E. Thickened choroid under areas of irregular RPE contour

A B-scan ultrasound with corresponding A-scan was completed and shown below. One can appreciate a choroidal lesion with small height and irregular contour, along with hyper-echoic margin and hypo-echoic core adjacent to the optic nerve. The initial spike on A-Scan is broad with possible fluid in initial caliper setting. Calipers may be too anterior to first spike on A-Scan here. A pearl is to try to place the initial choroidal caliper on the surface of the choroid lesion.

Question: Based on fundus photos, OCT of lesions, FAF and ultrasound images, what is the most likely diagnosis?

A. Choroidal nevus

B. Choroidal melanoma

C. Choroidal metastatic lesions

D. Pachychoroid disease spectrum

Question: Which of the following are treatment options for this patient?

A. Systemic immunomodulators

B. External beam radiation therapy

C. Photodynamic therapy

D. All of the above

Learning Objectives:

1. To understand the OCT features of choroidal metastatic disease.
2. To differentiate metastatic disease from choroidal melanoma.

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