Choroidal Melanoma Masquerading as Central Serous Chorioretinopathy

To determine the clinical features and outcomes of choroidal melanoma initially masquerading as central serous chorioretinopathy (CSCR).Retrospective case series.All patients with choroidal melanoma, initially misdiagnosed as CSCR elsewhere and evaluated by the Ocular Oncology Service at Wills Eye Hospital from 2004 to 2022, were included.A retrospective detailed review of patient charts and imaging was performed for all patients included in the study. Paired t tests and chi-squared tests were performed for data analysis.The primary outcome measures included clinical characteristics, ultrasonography, OCT, fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. The secondary outcome measures included treatment results, such as the final visual acuity, tumor control, radiation-related complications, and melanoma-related metastasis and death.There were 22 patients (mean age, 48 years; 16 men) in this cohort. The mean interval between initial CSCR diagnosis and suspicion of choroidal melanoma was 50 months (median, 50 months; range, 0-242 months). At tumor diagnosis, the melanoma was submacular in 16 (73%) patients and extramacular in 6 (27%) patients. The mean tumor thickness was 3.4 mm (median, 2.5 mm; range, 1.4-10.7 mm), and the mean basal diameter was 9.2 mm (median, 8.0 mm, range, 4.5-22.0 mm). Features enabling differentiation of choroidal melanoma from CSCR (affected versus unaffected eye) included choroidal thickness asymmetry (100%300 μm versus 21%300 μm; P = 0.005), ipsilateral choroidal surface irregularity (100% versus 0%; P0.001), loss of choroidal vascular detail on OCT (100% versus 0%; P0.001), presence of multiple pinpoint leaks on angiography (100% versus 0%; P0.001), and contralateral lack of autofluoresence abnormalities (75% versus 6%; P = 0.001). Management of the choroidal melanoma included plaque radiotherapy (19, 86%), enucleation (2, 9%), or treatment elsewhere (1, 5%). On follow-up (mean, 6 years), vision loss of ≥ 3 Snellen lines (9 patients, 47%), metastasis (3 patients, 14%), and death (1 patient, 5%) were noted.Patients with presumed CSCR, especially if chronic, should be evaluated for a possible thin underlying choroidal melanoma with a dilated fundus examination and multimodal imaging.