A 61-year-old man with no known medical history presented to the Emergency Department with two weeks of increasing abdominal distension. He also reported having progressive left eye pain and vision loss since a fall three years ago. The patient did not have a primary care physician and never saw an ophthalmologist. Physical examination revealed a firm abdomen with hepatomegaly. The left pupil was minimally-reactive and had an afferent pupillary defect. Left intraocular pressure was 34mmHg. Slit lamp examination of the left eye revealed iris neovascularization (solid arrow, Panel A), florid sentinel vessels (dashed arrow, Panel A), and tumor infiltration of the iris (dotted arrow, Panel A). Ultrasound demonstrated a large mass filling 80% of the left globe with low-internal reflectivity consistent with uveal melanoma. Computed tomography of the abdomen revealed hepatic hypodensities (arrow, Panel B) with hepatomegaly (24.4 cm); biopsy revealed metastatic melanoma. Vision loss attributed to a fall three years ago actually resulted from uveal melanoma that had since metastasized. The patient died 6 days later on home hospice.
Many hospitalists are familiar with cutaneous melanoma, but they may not be as aware of non-cutaneous forms of melanoma, such as uveal melanoma. Uveal melanoma is the most common primary malignancy of the eye in adults. In the U.S., the mean age-adjusted incidence of uveal melanoma is approximately 4.3 cases per million people. Uveal melanoma arises from intraocular melanocytes and has a different molecular pathogenesis than does cutaneous melanoma. The liver is the most common site of metastasis, and the images of our patient reinforce these valuable learning points. Prognosis is poor, with median survival ranging from 2-12 months. There is no cure for metastatic uveal melanoma. For patients who have a good performance status and reasonable life expectancy, treatment options with the goal of palliation include cytotoxic chemotherapy (e.g., cisplatin), immunotherapy (e.g., ipilimumab), or targeted therapy (e.g., BRAF inhibitors). Our patient was not a candidate for chemotherapy and desired to focus on comfort.
It is important to recognize that non-cutaneous forms of melanoma exist. Since uveal melanoma is the most common primary malignancy of the eye, and the liver is the most common site of metastasis, clinicians should consider metastatic uveal melanoma in patients presenting with vision loss and liver masses. The presence of sentinel vessels, iris neovascularization, and, if visible, mass infiltration in the iris should not be mistaken for more commonly-encountered cases of red eye such as conjunctivitis and should instead prompt the physician to consider ocular malignancy.
To cite this abstract:Cheng C, Park S. More Than Meets the Eye: Metastatic Uveal Melanoma. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 479. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/more-than-meets-the-eye-metastatic-uveal-melanoma/. Accessed April 10, 2020.