A 60-year-old man presents with a choroidal mass. Ultrasonography shows a mushroom-shaped choroidal lesion with acoustic hollowness (choroidal excavation) and high internal reflectivity anteriorly. FFA shows a 'double circulation' (tumour circulation visible before retinal circulation). The most likely diagnosis and first-line treatment is:
- A Choroidal haemangioma; transpupillary thermotherapy
- B Choroidal melanoma; Ruthenium-106 plaque brachytherapy or proton beam therapy for medium melanomas ✓
- C Choroidal metastasis; systemic chemotherapy with ocular radiotherapy
- D Disciform scar from AMD; anti-VEGF therapy
Explanation
Choroidal melanoma is the most common primary intraocular malignancy in adults. Classic ultrasonographic features: mushroom shape (due to Bruch's membrane break), choroidal excavation, acoustic hollowness (low internal reflectivity), and high anterior reflectivity (tumour surface). FFA double circulation (intrinsic tumour vasculature visible before retinal vessels fill) is characteristic. The COMS (Collaborative Ocular Melanoma Study) established that plaque brachytherapy (125-I or Ruthenium-106) is equivalent to enucleation for medium melanomas in terms of survival, preserving the eye. Choroidal haemangioma has high internal reflectivity without acoustic hollowness.
Reference: Khurana Comprehensive Ophthalmology, 7th ed.
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Written and medically reviewed by the StethoPrep medical team.