A 54-year-old man with new-onset type 2 diabetes mellitus comes to the physician for his first screening ophthalmologic examination. He has no eye symptoms and describes his vision as excellent. He does not smoke. His family history is significant for obesity and diabetes but negative for cancer. Funduscopic examination shows a small, densely pigmented lesion with irregular borders in the peripheral right choroid. The lesion is about 8 mm in diameter and is minimally raised (1 mm). Comprehensive skin examination is unremarkable. The patient is lost to follow-up. He returns 2 years later due to intermittent blurry vision. His HbA_1c is 8.2%. Repeat funduscopic examination shows that the pigmented lesion now measures 18 mm in diameter and its height is estimated at 4 mm. Comprehensive skin examination is unremarkable. Further evaluation shows no lesions beyond the right eye. Which of the following is the best next step in the management of this patient?

Question

Quizplus · Accepted Answer

Explanation: Large (diameter >10 mm, thickness >3 mm) choroidal melanomas or those presenting with associated symptoms (eg, eye pain, visual disturbances) have a worse prognosis than small asymptomatic lesions; patients should be referred for definitive treatment. Most patients with ocular melanoma requiring treatment will benefit from radiotherapy (brachytherapy or external beam radiotherapy), which has been shown to reduce mortality due to metastatic disease. (Choice A) Enucleation is the preferred treatment when the tumors are very large, have extrascleral extension, or severe associated pain. However, compared to radiotherapy, enucleation has greater functional and psychologic morbidity and no proven survival advantage. (Choice B) Photocoagulation of ocular melanoma and its surrounding small vessel blood supply has been advocated for small lesions and marginal recurrence following radiotherapy. However, this is inadequate for primary management of large lesions. (Choice D) This patient has uncontrolled diabetes mellitus and requires more aggressive management. However, the risk for further spread of melanoma is significant at this time, and definitive care should not be delayed. (Choice E) Chemotherapy has not proven effective in the treatment of intraocular melanoma. Educational objective: Patients with large or symptomatic choroidal melanomas require definitive treatment with radiotherapy. Enucleation is considered for very large tumors or tumors with extrascleral extension.

A 54-Year-Old Man with New-Onset Type 2 Diabetes Mellitus Comes