A Cataract is not always what it seems…

choroidal melanoma2

Since we’ve spent so many years studying ophthalmology, the subtleties of our field become second nature to us. We can glance at a person from across the room and instantly come up with a differential diagnosis. Sometimes we can even discern the correct diagnosis from history alone. We are able to instantly understand the prognosis of ocular pathology and the potential risks and complications of surgical procedures. Our patients don’t have this level of knowledge and it is our job to educate them and share our expertise.

For the past two years, a 30 year old patient noticed a gradual decline in his vision in his right eye. The other eye functioned fine, and due to lack of insurance coverage, he decided to defer medical treatment. What started as a shadow in his vision eventually turned into a partial blockage of his vision and then finally resulted in his vision dropping to no light perception. He did his own online research and figured that he had a cataract which could be fixed without much problem in the future.

Unfortunately, he was wrong. Examination of his right eye revealed no light perception vision and a corresponding afferent pupillary defect. The anterior segment had extensive rubeosis iridis and a ciliary flush with scant anterior chamber cells. The retina was detached and adherent to the posterior capsule of the crystalline lens which was relatively clear.


choroidal melanoma1
MRI scan shows a bright lesion inside the vitreous cavity of the right eye on the T1 image (A), which then appears dark on the T2 image (B). This bi-lobed lesion is approximately 10 x 15 mm in size and appears attached to the scleral wall. Fortunately, there were no brain lesions detected on this study.

B-scan ultrasound showed a complete funnel detachment with a large mass in the vitreous cavity. The MRI study shows the mass as 10mm x 15mm in dimension, bi-lobed, and attached to the scleral wall. After consultation with a colleague specializing in ophthalmic oncology, it was confirmed that the diagnosis was a choroidal melanoma. Surgery to enucleate the eye was performed and the histo-pathology showed an aggressive tumor which began to invade the scleral wall.

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At first glance, it appears that the patient has a whitish cataract (A), but in fact that white structure is the retina pushed up against the posterior capsule of a relatively clear crystalline lens. Further examination shows extensive rubeosis iridis (B) and hyperemia in a ciliary flush pattern (C).

In this case, the patient was completely shocked – and justifiably so because we just don’t expect to see these kinds of diagnoses in young and healthy patients. Hours were spent in detailed discussion with the patient and his family. This is situation where the seriousness of the diagnosis must be conveyed but care must be taken to treat the psychological state of the patient as well. Consider a team approach involving the patient’s family and other specialists. Block out enough time in your schedule to address all of the issues.

Fortunately, the patient is doing well and the systemic work-up and consultation with a medical oncologist did not reveal metastasis of the melanoma. While this case of choroidal melanoma is rare, the loss of vision can lead to loss of mobility and independence and it can have a detrimental effect on the patients affect and outlook on life.

We feel for our patients and we try our best to see things from their perspective. I was fortunate to have great mentors during my training and their words still echo in my mind as I interact with patients. But sometimes, there is no explanation why a patient is struck with a grave diagnosis or a complication from surgery.

The physician can empathize with the patient and simply say, “I’m sorry that you’re in this tough situation, but just know that I am here to help you any way that I can.” And we should remember that one day we will all likely be in their shoes, listening to our physicians explain the diagnoses, risks, or prognoses of our own personal medical and surgical challenges.


©2018 Uday Devgan MD. All rights reserved.

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