Title : Diagnostic uncertainty with a patient presenting with raised intra-ocular pressure. A unique case of choroidal melanoma
Abstract:
Introduction: This case report discusses a patient presenting with elevated intraocular pressure (IOP) unresponsive to oral or intravenous treatment, necessitating urgent cyclodiode intervention. Initial investigations revealed the possibility of either uveal melanoma or suprachoroidal haemorrhage. This case outlines, the patients’ clinical history, presentation and emphasises the importance of specialised referral for accurate diagnosis and management.
Methods: This 59 year old patient presented with acute glaucoma symptoms, including a painful red eye, vision loss, and headache lasting one week. Upon arrival at the Eye Casualty, several clinical examinations, including Snellen chart, intraocular pressure management, ocular surface assessments and ultrasonography were performed. The patients’ medical history was also reviewed and several forms of ocular imaging were performed.
Results: The patients’ IOP was critically elevated at 85 mmHg, and she exhibited significant corneal haze and a limited fundal view. The patient was admitted for intravenous (IV) mannitol. B-scan ultrasound revealed choroidal detachment, potentially due to suprachoroidal haemorrhage. A CT scan indicated a hyperdense right eye, raising concerns for haemorrhage, a tumour, or a chronic condition. Following this, an out-of-hours cyclodiode treatment was administered to reduce IOP. Post procedure IOP remained controlled. Ultrasound Bio-microscopy (UBM) was also conducted which showed laterally displaced lens and suprachoroidal haemorrhage or effusion. MRI showed high intrinsic T1 signal, dislocation of lens as well as retinal and choroidal detachment with differentials including choroidal melanoma and haematoma. She was subsequently referred to the Ocular Oncology team in Liverpool who confirmed choroidal melanoma and subsequently underwent enucleation of the right eye.
Conclusions: Differentiating between choroidal melanoma and haemorrhage can be challenging, as both conditions can appear similar on imaging studies. Suprachoroidal haemorrhage is rare and typically associated with a poor prognosis but a spontaneous suprachoroidal haemorrhage is even rarer especially in the absence of anticoagulant use. This case highlights the need for timely intervention in acute angle closure and careful diagnostic evaluation in ruling out secondary causes in patients presenting with ocular tumours and associated complications.
