SCC Online Series: it’s a wrap!

Differentiating choroidal melanoma

I joined about 200 optometrists online for the final session on 14 October to listen to Dr Sunil Warrier, ocular oncology specialist and head of ophthalmology at the Mater Hospital in Brisbane, present Differentiating choroidal melanoma from other pigmented lesions.

Elisa Lee, Specsavers clinical performance consultant for New South Wales, welcomed everyone with a brief introduction about the prevalence of ocular oncology. Across Specsavers ANZ, optometrists see roughly six patients per year with conjunctival melanoma, 24 patients with ocular surface squamous neoplasia, 29 with choroidal melanoma and three with anterior melanoma. Although the numbers aren’t huge, Specsavers anticipates seeing more than a million patients from mid-November to January and a significant number of those will present with an ocular lesion requiring referral.

Dr Warrrier begun his talk acknowledging that thanks to the upskilling of the optometry profession, ophthalmologists today are seeing patients with ocular lesions far sooner than in the past. Guiding the audience through diagnosis and management of ocular lesions, he shared some interesting cases, including patients with choroidal naevus, the most common lesion optometrists see in practice; choroidal melanoma, the most common primary intraocular malignancy in adults; choroidal metastasis; and choroidal haemangioma. He also shared a few less typical cases, including a patient with congenital hypertrophy of the retinal pigment epithelium (CHRPE), vasoproliferative tumours and the rare hereditary condition Von-Hippel Lindau, characterised by tumors arising in multiple organs, including haemangioblastomas.

Diagnosing choroidal melanoma, Dr Warrier recommended using the SPOTS US mnemonic as safe and thorough practice: size (S), position (P), orange lipofuscin (O), thickness (T), subretinal fluid (S) and ultrasound showing an acoustic hollow (US).

Symptoms optometrists should look for include flashes, persistent blurry vision and rarely floaters but often some metamorphopsia. Following the mnemonic, using optical coherence tomography (OCT) and ultrasound, optometrists need to assess the lesion’s size, is it positioned close to the optic nerve (but it doesn’t have to be, often the very nasty ones aren’t), is it showing orange lipofuscin, how thick is it, is it showing signs of leaking fluid (the OCT will show subretinal fluid) and, lastly, looking at the ultrasound, a low internal reflectivity confirms it’s a choroidal melanoma.

Small lesions can be treated with photodynamic laser therapy (PDT). This maintains patient vision but results in a higher risk of reoccurrence. Life-threatening lesions can be treated with brachytherapy, which involves applying radioactive discs to the inside of the eye for 24-72hrs. This method is very successful at killing the tumour, said Dr Warrier, but won’t prevent metastases. Dry eye, cataracts and some vision loss are common side effects.

Lesions bigger than 8mm aren’t suited for radiotherapy but can be removed through enucleation. Interestingly, some patients prefer this to feel secure that the tumour has been completely removed and they don’t have to go through regular check-ups and monitoring, said Dr Warrier. Metastatic ocular disease often results in a bad prognosis and usually spreads to the patient’s liver, he added, and while immunotherapy is effective in some other cancers, this is sadly not the case with ocular cancers.

Dr Warrier’s presentation ended with a questions-and-answer session, which covered managing patients with CHRPEs, prothesis eyecare and naevus turning into melanoma. He ended by saying it is always best to err on the side of caution with something that can be potentially life threatening. “With your skillset and the technology at your disposal, you can make a difference to peoples’ sight and their lives.”