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 Table of Contents    
CLINICAL IMAGE
Year : 2019  |  Volume : 12  |  Issue : 1  |  Page : 62-64  

Retinal detachment with hemorrhagic intraretinal macrocyst clinically presenting as pseudo-choroidal melanoma


Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India

Date of Web Publication30-Jan-2019

Correspondence Address:
Dr. Pukhraj Rishi
Senior Consultant, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Medical Research Foundation, 18, College Road, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.OJO_136_2018

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   Abstract 


A 23-year male with complaint of diminution of vision in left eye was referred to us as a suspect case of inflammatory choroidal mass/melanoma. Examination revealed a total retinal detachment with a reddish brown lesion in the superior hemi-fundus. B-scan ultrasonography demonstrated the 'mass' to be intra-retinal without choroidal involvement. A diagnosis of haemorrhagic intraretinal macrocyst (HIM) was made. We report this case to highlight the importance of correctly diagnosing an HIM and utilizing ultrasound to rule out choroidal pathologies, especially melanoma. This is essential as the management and prognosis of the two disorders is entirely different.

Keywords: B-scan ultrasonography, choroidal melanoma, haemorrhagic intraretinal macrocyst, retinal detachment


How to cite this article:
Naik AU, Rishi P, Prakash V J, Rishi E. Retinal detachment with hemorrhagic intraretinal macrocyst clinically presenting as pseudo-choroidal melanoma. Oman J Ophthalmol 2019;12:62-4

How to cite this URL:
Naik AU, Rishi P, Prakash V J, Rishi E. Retinal detachment with hemorrhagic intraretinal macrocyst clinically presenting as pseudo-choroidal melanoma. Oman J Ophthalmol [serial online] 2019 [cited 2019 Mar 20];12:62-4. Available from: http://www.ojoonline.org/text.asp?2019/12/1/62/251026



A 23-year-old Indian male patient presented with diminution of vision in the left eye for 1 month. He had been diagnosed elsewhere as an inflammatory mass/choroidal melanoma. Best-corrected visual acuity (BCVA) in the right eye was 6/6, N6 and that in the left eye was 2/60, N36. Ocular evaluation of the right eye was within normal limits. Except for left-sided relative afferent pupillary defect, anterior segment examination was unremarkable in the left eye. The left eye had total retinal detachment with a well-circumscribed reddish-brown dome-shaped lesion in superior fundus [[Figure 1], white arrows]. Ultrasound B-scan demonstrated retinal detachment with the splitting of superior retinal layers [Figure 2], white arrow], encapsulating plenty of variable reflective dot echoes. Choroid was distinct from the lesion. Based on these findings, a diagnosis of hemorrhagic intraretinal macrocyst (HIM) was made. The patient underwent scleral buckling that failed to resolve the retinal detachment and the HIM. Subsequently, pars plana vitrectomy, cyst drainage, endolaser, and silicone oil tamponade was performed. Six weeks postsurgery, the patient had an attached retina [Figure 3] with BCVA of 3/60, N36. Six months later, the patient subsequently developed a posterior subcapsular cataract. He underwent phacoemulsification with in-the-bag intraocular lens implantation and silicone oil removal in the same sitting [Figure 4]. Six weeks postoperatively, BCVA was noted as 6/60, N24.
Figure 1: Left eye color fundus image (montage) at presentation. Total retinal detachment at presentation with a reddish-brown mass lesion in the superior aspect (white arrows). Inset: the surface of the lesion with retinal vessels (blue arrow) over it

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Figure 2: Left eye B-scan at presentation. The mass lesion (white arrow) was intraretinal and distinct from the choroid. Multiple mobile variable reflective dot echoes were noted within the lesion, suggestive of hemorrhage

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Figure 3: Postoperative fundus image 6 weeks after a pars plana vitrectomy, cyst drainage, endolaser, and silicone oil tamponade. (captured on Daytona ultra-widefield scanning laser ophthalmoscope, Optos Inc., Marlborough, Massachusetts, USA)

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Figure 4: Postoperative fundus image after phacoemulsification, intra-ocular lens implantation and silicone oil removal (captured on Daytona ultra-widefield scanning laser ophthalmoscope, Optos Inc., Marlborough, Massachusetts, USA)

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Retinal macrocysts are asymptomatic, single or multiple cavities that are associated with long-standing retinal detachment, particularly of the traumatic type.[1] They can range from 2 to 10 disc diameters in size and occur in 1%–3% of long-standing retinal detachments.[2],[3] Their exact pathogenesis is unknown, but they are believed to arise either due to photoreceptor atrophy secondary to choroidal ischemia or degenerative cystic changes in the outer plexiform layer.[4] These cysts are usually filled with fluid and occasionally with blood. Intra-retinal macrocysts may mimic and hence need to be differentiated from retinoschisis, malignant choroidal melanoma, circumscribed choroidal hemangioma, sub-retinal abscess, posterior scleritis, and other simulating lesions such as toxocariasis, medulloepithelioma, and intraocular choristoma.[5] Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) also needs to be considered, especially in elderly patients. Most cysts resolve spontaneously on retinal re-attachment but may need drainage if they prevent retinal re-attachment. Ultrasound is the investigation of choice to differentiate a HIM from choroidal pathologies, especially a melanoma which is at the level of choroid with characteristic mushroom/collar-button shape and demonstrates unique features such as acoustic attenuation and choroidal excavation. This differentiation is extremely important as the treatment options and the visual outcome of these pathologies are completely different.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Marcus DF, Aaberg TM. Intraretinal macrocysts in retinal detachment. Arch Ophthalmol 1979;97:1273-5.  Back to cited text no. 1
    
2.
Schepen CL. Retinal Detachment and Allied Diseases. 2nd ed. Philadelphia: W.B. Saunder; 2000. p. 201.  Back to cited text no. 2
    
3.
Goel SD, Augsburger JJ. Hemorrhagic retinal macrocysts in advanced coats disease. Retina 1991;11:437-40.  Back to cited text no. 3
    
4.
Patil BB, Mowatt L, Ho S, Scott RA, Siddiqi R. Asymptomatic bilateral simultaneous rhegmatogenous retinal detachments. Eye (Lond) 2005;19:820-1.  Back to cited text no. 4
    
5.
Rishi P, Rishi E, Sen PR, Sharma T. Hemorrhagic intraretinal macrocyst: Differential diagnoses and report of an unusual case. Oman J Ophthalmol 2011;4:28-31.  Back to cited text no. 5
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