December 15, 2022
Authored by: Danielle Strauss, MD
CC: A 32 year-old African-American woman was referred to me for a finding on the optic nerve of the left eye. The patient had no visual complaints. She denied a scotoma, photopsias or floaters.
PMHX: none, denied pregnancy
Past ocular history: None
Family history: Father has glaucoma BCVA cc: 20/20 OD, 20/20 OS
IOP: 26 OD, 28 OS
No APD unremarkable
DFE: see imaging below
Widefield color fundus photo of the right eye showed a healthy appearing optic nerve, and a flat and attached retina.
Widefield photo of the left eye showed a hyperpigmented lesion surrounding the optic nerve and involving the inferior retina. There is obscuration of the inferior aspect of the nerve.
Magnified color photo of the lesion
Fundus autofluorescence shows the lesion to be hypo-autofluorescent
Baseline 24-2 visual field testing showed a full field in the right eye, and dense inferior and superior arcuate defects in the left eye.
Assessment, differential diagnosis and plan:
The differential diagnosis for this 32 year old African-American woman with a unilateral pigmented disc lesion and arcuate visual field defects includes the following:
1) Choroidal melanoma
2) Choroidal Nevus
3) Combined hamartoma of the retina and RPE
4) Optic disc melanocytoma
5) Metastatic melanoma to the optic disc
Diagnosis and Plan:
I suspected the lesion to be a benign optic disc melanocytoma based on the clinical features. An optic disc melanocytoma is a benign, unilateral tumor that rarely transforms into a malignant lesion. It is a congenital lesion that predominantly occurs in caucasian (65%) women. Examination may reveal an APD in the involved eye, however patients are generally asymptomatic. Visual field testing, however, will be abnormal in 90% of cases, with arcuate visual field defects. Rarely, the lesion may grow over time and encompass the adjacent retina or choroid. Also, vitreous seeding is a rare complication of the lesion which may lead to retinal neovascularization.
In this case, I had the patient see Dr. Maley, one of our glaucoma specialists, who started her on latanoprost qhs ou for the IOP elevation. I also had the patient see an ocular oncologist to reassure the patient that this was indeed a benign lesion and not a melanoma. The ocular oncologist agreed with my assessment. Our plan is for both Dr. Maley and I continue to monitor the patient going forward.