Ciliary body melanoma revealed by painful ocular hypertension: An unusual clinical presentation (a case report)

Background: Ciliary body melanoma is a rare intraocular malignancy, accounting for less than 5% of uveal melanomas. Due to its retro iridal location and late functional manifestations, diagnosis may be delayed. Although visual impairment is the most common presenting symptom, ocular pain and secondary ocular hypertension are uncommon and may lead to diagnostic confusion.

Case Presentation: We report the case of a 47-year-old man with no significant medical history who presented with rapidly progressive visual loss, ocular pain, and redness of the left eye, without any history of trauma. Visual acuity was reduced to counting fingers at 1m. Slit-lamp examination revealed superior episcleral sentinel vessels, superior iridocorneal synechiae, an irregularly deep anterior chamber, fixed mydriasis, superior iris bulging with rubeosis, and marked pigment dispersion on the anterior lens capsule. Intraocular pressure was markedly elevated at 53 mmHg, and fundus examination was not possible. B-scan ultrasonography was unremarkable. Orbital MRI revealed a 3,6-mm intraocular lesion showing T1 hyperintensity and T2 hypo intensity, highly suggestive of a melanocytic tumor. Systemic staging was negative.

Given the severity of the clinical presentation and secondary glaucoma, enucleation was performed. Histopathological examination confirmed a 5-mm ciliary body melanoma with scleral invasion. Adjuvant external beam radiotherapy was subsequently administered. After 18 months of follow-up, the patient remained free of metastasis.

Conclusion: Ciliary body melanoma should be considered in the differential diagnosis of unexplained painful ocular hypertension, particularly when associated with sentinel episcleral vessels, pigment dispersion, iris distortion, or rubeosis. Its occult location can delay diagnosis and adversely affect prognosis. Careful anterior segment examination and appropriate imaging, particularly ultrasound biomicroscopy and MRI, are essential for early detection. Scleral invasion represents an important prognostic factor and may influence the therapeutic strategy. This case highlights the importance of considering an underlying intraocular tumor in atypical cases of secondary glaucoma.