Choroidal Melanoma presenting as serous macular detachment - 2025 11 14 Albert Xiong, MD

This case presentation describes a 72-year-old woman with subacute visual decline in the right eye initially diagnosed as central serous retinopathy, who was later found to have a pigmented, elevated choroidal lesion superotemporally with associated serous retinal detachment involving the fovea. Her history was notable for prior cutaneous melanoma and carcinoid tumors, raising concern for a malignant intraocular process. Careful examination beyond the macula revealed the underlying choroidal mass, emphasizing the importance of a complete posterior pole evaluation when serous macular detachment is present. The teaching points begin with a review of the differential diagnosis for a pigmented choroidal lesion associated with subretinal fluid, including choroidal nevus, CHRPE, melanocytoma, metastasis, posterior uveitis, and choroidal melanoma. Choroidal melanoma is the most common primary intraocular malignancy and often presents as a dome-shaped pigmented mass with irregular margins, sometimes with minimal or nonspecific symptoms. No single clinical feature is diagnostic, making multimodal imaging and pattern recognition critical for accurate diagnosis. The final teaching section focuses on diagnostic imaging and management. Ultrasound typically shows medium to low internal reflectivity on A-scan with a decrescendo pattern and an acoustically hollow, dome-shaped lesion on B-scan, often with associated subretinal fluid. Fundus autofluorescence may reveal lipofuscin, and OCT can help characterize associated retinal changes. Management decisions are guided by tumor size, location, and systemic considerations, with options ranging from close observation of suspicious nevi to plaque brachytherapy or enucleation. Large clinical trials have demonstrated similar survival outcomes for brachytherapy and enucleation in appropriately selected patients, reinforcing the role of eye-sparing treatment when feasible.