Choroidal Melanoma

Choroidal Melanoma

Malignant "choroidal" melanoma can grow within the eye. They arise from the blood-vessel layer "choroid" beneath the retina. In North America, 6 out of each million people will get a choroidal melanoma each year. Malignant choroidal melanomas can spread to other parts of the body.

Eye cancer specialists determine if you have a choroidal melanoma by performing a complete eye examination. This includes asking questions about your medical history, examining both of your eyes, looking into the eye at the tumor, doing an ultrasound examination, and specialized photography (to examine the circulation within the choroidal melanoma).

Your specialist will also request that you have a complete general medical check up and specific tests depending upon what they see inside your eye. Eye cancer specialists can correctly diagnose an intraocular choroidal melanoma in over 96% of cases (without a biopsy). Though occasionally necessary, biopsies are usually avoided because they require opening the eye (which risks letting choroidal melanoma cells out) and risk intraocular hemorrhage and infection.

Symptoms
Most choroidal melanoma patients have no symptoms and the melanoma is found on routine eye examination. If patients have symptoms, they are usually: seeing "flashes of light," "distortion" or loss of vision, and floating objects (floaters) in the vision.

1) If the choroidal melanoma is in the front of the eye, near the lens, it can push or tilt the natural lens causing an irregular astigmatism (blurring of vision).

2) Choroidal melanoma can leak fluid beneath the retina, making it detach and cause symptoms of flashing lights and floating specks.

3) If the choroidal melanoma is in the macula (center of vision), it can grow beneath the fovea making the patient far-sighted. The choroidal melanoma can also grow into and destroy the fovea causing distortion, loss of vision or changes in color perception.

It is important to note that most patients with choroidal melanoma have no symptoms at all. Their tumors are found when they visit their eye doctor for a "routine" eye examination. So everyone should have periodic eye examinations (including dilated ophthalmoscopy).

Other, more unusual presentations of anterior choroidal and iridociliary melanoma are discoloration of the iris, a brown spot on the outside of the eye, an irregularly shaped pupil and glaucoma.

Diagnosis
Choroidal melanoma can be seen by ophthalmoscopy (when your eye doctor looks through a lens into your dilated pupil).

Choroidal melanoma has typical "diagnostic" characteristics that include but are not limited to: pigmentation, thickness, low or moderate internal ultrasound reflectivity, orange pigment on its surface, and leakage of fluid or retinal detachment (on or around the choroidal melanoma).

1) Choroidal melanoma pigment is due to naturally occuring melanin that comes from melanocyte cells in the choroidal layer. Choroidal melanoma is usually pigmented, but they can be variably pigmented and even amelanotic (non-pigmented). Nonpigmented choroidal melanoma is due to a proliferation of melanocytes that have lost their ability to make melanin pigment.

Choroidal Melanoma with Orange Pigment

Dome-shaped choroidal melanoma

A collar-button shaped choroidal melanoma with orange pigment, subretinal fluid, and thickness greater than 2 mm: all consistent with choroidal melanoma.

A dome-shaped choroidal melanoma with orange pigment, subretinal fluid, and thickness greater than 2 mm: all consistent with choroidal melanoma.

2) Orange pigment (lipofuscin) on the choroidal melanoma indicates that cells are dying on the tumor's surface. This is a sign of metabolic activity.

3) Ultrasound is typically used to measure the choroidal melanoma size, evaluate internal tumor reflectivity, and look for melanoma extension behind the eye into the orbit (extrascleral extension). Ultrasound shows that most choroidal melanomas are shaped like a dome and less commonly like a mushroom. Ultrasound can also evaluate choroidal melanoma associated retinal detachment.

Ultrasound of a collar-button shaped Choroidal Melanoma

Ultrasound of dome-shaped choroidal melanoma

4) Leakage can occur on or around a choroidal melanoma. This finding indicates that the melanoma has poorly formed "leaky" blood vessels or that it is eroding through the overlying membranes (Bruch's and the retinal pigment epithelium) that separate the leaking choroid from the overlying retina. Leakage beneath the retina causes it to detach (retinal detachment). The size of the detachment can range from a small cap of fluid over the tumor, to a large serous retinal detachment.

If the diagnosis of choroidal melanoma is made by your eye care professional, it is reasonable to have it confirmed by an eye cancer specialist.

Treatments
Small Choroidal Melanoma:
Patients with a small choroidal melanoma can be treated after their first visit, but since growth helps to prove that the tumor is a cancer, your doctor may suggest "observation" or watching for a small amount of choroidal melanoma growth prior to treatment. Your eye cancer specialist should discuss the relative risks and potential benefits of both "observation for growth" as compared to "immediate treatment" for choroidal melanoma. Once growth is documented, eye cancer specialists will recommend definitive treatment.

Medium-sized Choroidal Melanoma:
Around the world, most patients with a medium-sized choroidal melanoma are treated with either radiation therapy or removal of the eye. Though there are several forms of eye and vision sparing radiation therapy, ophthalmic plaque radiation therapy is the most common and widely used.

Since the results of the Collaborative Ocular Melanoma Study (COMS) suggest that plaque radiation therapy and enucleation of the eye are equally effective for the prevention of metastatic choroidal melanoma, few patients with medium-sized choroidal melanoma are treated by removal of the eye.

In that both enucleation and plaque radiation therapy for choroidal melanoma are likely to harm your vision (in that eye). You should discuss the risks and benefits of these and other treatment options in consultation with your eye cancer specialist.

Large-sized Choroidal Melanoma:
A patient with a very large choroidal melanoma may be treated by removal of the eye (enucleation). This is because the amount of radiation required to kill a choroidal melanoma that fills most of the eye may be too much for the eye to tolerate.

However, most patients with large-sized choroidal melanoma can be also be treated with eye-sparing radiation therapy. After radiation for large choroidal melanoma, these eyes are at greater risk to have poor vision, to become uncomfortable and may have to be secondarily removed.

Additional Info
It is important to note that as compared to like-sized malignant melanoma of the skin, patients are much more likely to survive a choroidal melanoma. This is because it is much more difficult for a choroidal melanoma to spread from (get out of) the eye to other parts of the body. However, large (choroidal melanoma) tumor size decreases the chance that vision-sparing treatments will be successful. In general, the larger the choroidal melanoma the worse the prognosis for both vision and metastasis.

Dr Finger suggests you protect your eyes from ultraviolet radiation. He says, "Think of Sunglasses as Sun Block for your Eyes" ™

Patients often ask why they have a choroidal melanoma. Choroidal melanoma is more common among patients with blue vs. brown eyes, those with outdoor occupations and in Australia where there is an ozone hole. Therefore, it seems reasonable to assume (though unproven) that choroidal melanoma is related to sunlight (ultraviolet exposure). In that sunlight exposure has been linked to several eye cancers and diseases of the eye, Dr. Finger suggests that you "Think of Sunglasses as Sun Block for your Eyes" ™ and start wearing your UV blocking sunglasses. They make great gifts too!

Related Links
View photographs of choroidal melanoma, choroidal nevus and other choroidal tumors

View ultrasound images of choroidal melanoma and other ocular tumors

A comparison of plaque versus proton radiation for choroidal melanoma

A comparison of iodine-125 versus palladium-103 eye plaque radiation therapy

About Eye and Vision-Sparing Treatments for Choroidal Melanoma

What is "Enucleation for Choroidal Melanoma?'

What some patients look like after enucleation for choroidal melanoma

Read about the "Finger Classification of Radiation Retinopathy" and how it predicts vision loss.

An overview of treatments for metastatic choroidal melanoma

An overview of systemic chemotherapy

Images related to radiation therapy for choroidal melanoma

An article about PET/CT to monitor for metastastic choroidal melanoma.

PET/CT SUV found to be a biomarker for the risk of metastasis from choroidal melanoma

Why choroidal melanoma specialists should use a standardized classification "language."

Ocular prosthesis care after enucleation for choroidal melanoma

Scientific Articles about choroidal melanoma written by Dr. Finger

The Collaborative Ocular Melanoma Study (COMS): What is it? What did it show?

Dr. Finger shows how three-dimensional (3D) ultrasound can be used to make sure the plaque is placed correctly

Dr. Finger explains why patients should use ultraviolet blocking sunglasses to protect their eyes.

An overview of treatment for metastatic choroidal melanoma

Compare the results after iodine-125, ruthenium-106 and palladium-103 plaque therapy for choroidal melanoma

About extrascleral extension of choroidal melanoma

Frequently asked questions about choroidal melanoma

Frequently asked questions about enucleation for choroidal melanoma

Frequently asked questions about plaque radiation therapy for choroidal melanoma

How can I contribute to choroidal melanoma cancer research?

Other patients with choroidal melanoma can be found on our bulletin board - Register on the home page

Learn more about The New York Eye Cancer Center's approach to treatment of choroidal melanoma

To Treat or Not to Treat - The Small Choroidal Melanoma Controversy

Radiation Maculopathy and Optic Neuropathy Is treatable with Anti-VEGF Therapy

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