Multimodal imaging of suspicious choroidal neoplasms in a primary eye‐care clinic

Abstract

Small suspicious choroidal neoplasms commonly present a diagnostic challenge in primary eye-care clinics, where they are most likely to present. Differentiating benign from malignant choroidal neoplasms is essential for facilitating early diagnosis and treatment, potentially decreasing the risk of metastasis and vision loss in some cases. The purpose of this review is to describe the clinical, spectral-domain optical coherence tomography and fundus autofluorescence features of suspicious choroidal neoplasms in a case series of patients presenting to a primary eye-care clinic at the Veterans Health Administration, Cleveland, Ohio, USA.Key words: benign choroidal neoplasm, choroidal melanoma, choroidal metastasis, choroidal naevus, fundus autofluorescence, optical coherence tomography, sclerochoroidal calcification Primary eye-care providers are likely to encounter patients with suspicious choroidal lesions during routine clinical examination. The choroid can be a harbour of malignant neoplasms, such as choroidal melanoma and metastasis.1 Other benign choroidal lesions may have overlapping clinical features that mimic malignancies, many times precluding an accurate diagnosis and requiring consultation with a retinal or ocular oncology ophthalmologist. With access to high-resolution spectral-domain optical coherence tomography (SD-OCT), optometrists are able to evaluate microstructural retinal and choroidal changes, allowing better characterisation of suspicious choroidal lesions. SD-OCT is also used to perform enhanced-depth imaging OCT (EDI-OCT) to increase the resolution of structures posterior to the retinal pigment epithelial (RPE) layer, specifically the choroid and sclera, further expanding the ability to evaluate subretinal lesions. Fundus autofluorescence is another useful imaging tool for evaluating retinal changes associated with choroidal lesions. Fundus autofluorescence highlights the presence of lipofuscin, a clinical finding known to have strong association with malignant choroidal lesions. SD-OCT systems such as Topcon 3D OCT-2000 (Topcon Medical Systems, Inc., Oakland, New Jersey, USA) and Heidelberg Spectralis HRA+OCT (Heidelberg Engineering, Heidelberg, Germany) are equipped with fundus autofluorescence imaging, which is able to highlight areas of RPE distress caused by the underlying effects of invasive or spaceoccupying choroidal lesions. Combined analysis of SD-OCT and fundus autofluorescence, referred to as multimodal imaging, can enhance the evaluation process for suspicious choroidal lesions, possibly facilitating an earlier diagnosis and conversely, preventing false-positive referrals for benign choroidal lesions. Herein, we describe the clinical, SD-OCT and fundus autofluorescent features of small suspicious choroidal neoplasms and mimicking lesions, both benign and malignant, in a case series of patients presenting to a primary eye-care clinic at the Veterans Health Administration, Cleveland, Ohio, USA. METHODSof the choroidal neoplasm was plotted manually at the location judged to b...

Multiple bilateral choroidal metastases in stage IV lung cancer

“…Optical coherence tomography imaging of a metastasis can reveal a distinctive undulated anterior tumour profile. In comparison, choroidal melanomas have a smoother dome‐shaped anterior tumour profile unless there is penetration of Bruch's membrane due to a mushroom‐shaped neoplasm …”

“…In comparison, choroidal melanomas have a smoother dome-shaped anterior tumour profile unless there is penetration of Bruch's membrane due to a mushroom-shaped neoplasm. 1,5 Recognising the clinical characteristics of choroidal metastases can facilitate more timely diagnosis and treatment. First-line treatment is often the continuation of systemic treatment, such as chemotherapy or immunotherapy.…”

The advantages of intermediate‐tier, inter‐optometric referral of low risk pigmented lesions

“…In contrast, large drusen on the surface of a choroidal naevus might appear as discrete spots of hyper‐autofluorescence, while subretinal fluid typically displays a mildly hyper‐autofluorescent leading edge or gravitational effect . Dark, hypo‐autofluorescent areas associated with pigmented posterior eye lesions typically evolve over time, coinciding with degeneration and/or atrophy …”

“…Most pertinently, fundus autofluorescence imaging can enhance the ability to visualise orange pigment (lipofuscin) on a tumour's surface associated with malignancy, which colocalises with distinct hyper‐autofluorescence . In contrast, large drusen on the surface of a choroidal naevus might appear as discrete spots of hyper‐autofluorescence, while subretinal fluid typically displays a mildly hyper‐autofluorescent leading edge or gravitational effect . Dark, hypo‐autofluorescent areas associated with pigmented posterior eye lesions typically evolve over time, coinciding with degeneration and/or atrophy …”