A 55-year-old man with metastatic cancer develops sudden deterioration of vision in one eye. Fundus examination reveals a dome-shaped, orange-brown subretinal lesion in the choroid at the posterior pole, with associated exudative retinal detachment. B-scan ultrasound shows a dome-shaped lesion with high internal reflectivity. FFA shows a 'double circulation' pattern and 'hot spot' early hyperfluorescence. The most likely diagnosis is:
- A Uveal melanoma
- B Choroidal metastasis ✓
- C Choroidal haemangioma
- D Disciform scar from exudative AMD
Explanation
Choroidal metastasis is the most common intraocular malignancy overall (commoner than melanoma, particularly in patients with known primary cancer). It classically presents as a yellowish-white (not pigmented) or orange-brown flat-to-dome shaped subretinal lesion, often bilateral and multifocal, with large exudative retinal detachment disproportionate to the lesion size. FFA shows early mottled hyperfluorescence and late staining. Uveal melanoma has low internal reflectivity on B-scan ('quiet zone'), mushroom configuration (Bruch's membrane rupture), and 'melanoma collar stud' appearance. Choroidal haemangioma appears as an orange-red lesion with very high internal reflectivity (echo-dense) on B-scan and intense early hyperfluorescence. Disciform scar has a flat grey-white appearance with no dome.
Reference: Khurana Comprehensive Ophthalmology, 7th ed.
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Written and medically reviewed by the StethoPrep medical team.