Choroidal tumors comprise a heterogeneous group of intraocular lesions ranging from benign entities such as choroidal nevus and circumscribed choroidal hemangioma to malignant tumors including uveal melanoma and choroidal metastasis. Accurate differentiation is crucial, as management and prognosis exhibit significant variations.Choroidal nevi are the most prevalent benign intraocular tumors and are generally asymptomatic. However, a small subset of these nevi carries a risk of malignant transformation into melanoma. Risk stratification utilizing multimodal imaging criteria, such as the TFSOM-DIM and MOLES systems, is pivotal in clinical decision-making.Uveal melanoma represents the most common primary intraocular malignancy in adults and is associated with high metastasis rates, particularly to the liver. Prognosis depends on tumor size, location, histopathologic features, and molecular alterations such as monosomy 3 or BAP1 loss. Treatment options range from globe-preserving radiotherapy to adjuvant or neoadjuvant surgical resection and enucleation in advanced cases.Choroidal hemangioma is a benign vascular tumor that can lead to visual impairment due to exudative retinal detachment. Photodynamic therapy is currently considered the preferred treatment in symptomatic cases.Choroidal metastases represent the most prevalent intraocular malignancies, with a primary origin in breast or lung carcinoma. Multimodal imaging is essential for diagnosis and monitoring, and management requires interdisciplinary coordination.A structured multimodal diagnostic approach is crucial for accurate classification, risk assessment, and individualized therapeutic planning in patients with choroidal tumors.

The choroid of the eye is a rare site for metastatic tumor spread, and as small lesions on the periphery of brain MRI studies, these choroidal metastases are often missed. To improve their detection, we aimed to use artificial intelligence to distinguish between brain MRI scans containing normal orbits and choroidal metastases. We present a novel hierarchical deep learning framework for sequential cropping and classification on brain MR images to detect choroidal metastases. The key innovation of this approach lies in training an orbit localization network based on a YOLOv5 architecture to focus on the orbits, isolating the structures of interest and eliminating irrelevant background information. The initial subtask of localization ensures that the input to the subsequent classification network is restricted to the precise anatomic region where choroidal metastases are likely to occur. In step 1, we trained a localization network on 386 T2-weighted brain MRI axial slices from 97 patients. Using the localized orbit images from step 1, in step 2 we trained a binary classifier network with 33 normal and 33 choroidal metastasis-containing brain MRIs. To address the challenges posed by the small data set, we used a data-efficient evolutionary strategies approach, which has been shown to avoid both overfitting and underfitting in small training sets. Our orbit localization model identified globes with 100% accuracy and a mean average precision (mAP) of intersection over union thresholds of 0.5-0.95 [mAP(0.5:0.95)] of 0.47 on held-out testing data. Similarly, the model generalized well to our step 2 data set, which included orbits demonstrating pathologies, achieving 100% accuracy and mAP(0.5:0.95) of 0.44. mAP(0.5:0.95) appeared low because the model could not distinguish left and right orbits. Using the cropped orbits as inputs, our evolutionary strategies-trained convolutional neural network achieved a testing set area under the curve of 0.93 (95% CI, 0.83-1.03), with 100% sensitivity and 87% specificity at the optimal Youden index. The semiautomated pipeline from brain MRI slices to choroidal metastasis classification demonstrates the utility of a sequential localization and classification approach, and clinical relevance for identifying small, "corner-of-the-image," easily overlooked lesions. Artificial Intelligence Level of Evidence: 5B.

Choroidal Metastasis in a Man with Breast Cancer Causing Retinal Detachment.

Ocular manifestations rarely represent the first sign of systemic malignancy and often pose a diagnostic challenge. While choroidal metastases are more common, iris involvement is uncommon and may be underrecognized. Lung adenocarcinoma, particularly non-small cell subtypes, is a known source of ocular metastases, with iris lesions occasionally preceding systemic symptoms. We report a 70-year-old previously healthy man presenting with one month of left eye blurred vision. Initial examination revealed conjunctival injection and visual acuity of 6/20 without detectable lesions; topical dexamethasone was prescribed. Six weeks later, vision declined to finger counting, and a hypopigmented iris mass (7.0 × 5.7 mm) was identified. A brain MRI revealed a right occipital lesion, and a CECT of the thorax, abdomen, and pelvis showed a left lung mass with bilateral nodules, mediastinal lymphadenopathy, and right iliac metastasis. CT-guided biopsy confirmed stage IV lung adenocarcinoma (TTF-1 and Napsin A positive, PD-L1 TPS 80%, EGFR/ALK/ROS1 negative). Pembrolizumab was initiated; filamentous keratitis developed during therapy, and progression at three months prompted conventional chemotherapy. This case emphasizes the rarity of iris metastasis as the initial presentation of lung adenocarcinoma.

Introduction: Choroidal metastases are the most common intraocular malignancies, with breast carcinoma being the leading primary tumor in women. Bilateral involvement associated with exudative retinal detachment is uncommon and potentially sight-threatening. Case Presentation: A 31-year-old black woman with a history of left breast carcinoma treated by mastectomy and adjuvant chemoradiotherapy presented with progressive visual loss and photopsia in both eyes. Fundus examination revealed bilateral exudative retinal detachment with macular involvement in the left eye. Multimodal imaging using fundus photography, B-scan ultrasonography and computed tomography demonstrated bilateral choroidal masses consistent with metastatic disease. Despite referral for systemic oncological management, the patient declined chemotherapy and was followed for 33 days, showing progression of the choroidal lesions. Conclusion: Choroidal metastases should be suspected in any patient with breast cancer presenting with visual symptoms. Multimodal ocular imaging is crucial for diagnosis.

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Choroidal metastasis is the most common intraocular malignancy. However, bilateral involvement remains exceptionally rare. We describe a case of a 57-year-old patient with no comorbidity who presented with progressive decrease in visual acuity of both eyes for 5 months duration. Fundus examination of both eyes revealed choroidal masses in the posterior pole with serous retinal detachment. She did not exhibit any respiratory symptoms, and systemic examinations were normal. Systemic investigation including computed tomography thorax revealed patient had lung tumour [...]

To develop and validate a deep-learning model for detecting choroidal metastasis and predicting primary cancer sites using ultra-widefield fundus photography (UWFP). This retrospective cohort study utilized 719 UWFP images from 112 patients with choroidal metastasis and 288 normal photos from 288 patients treated at Severance Hospital between 2005 and 2023. A Vision Transformer model, enhanced by transfer learning and image augmentation, was developed and evaluated using AUROC, accuracy, sensitivity, and specificity. Cross-validation, bootstrap sampling, and ablation studies were conducted to ensure robustness and interpretability. The model achieved an AUROC of 0.96 for detecting choroidal metastases, significantly outperforming ophthalmologists (AUROC 0.69). Incorporating age and sex information enhanced model performance, yielding AUROCs of 0.87 for lung cancer and 0.96 for breast cancer. Ablation studies confirmed that fundus image features were the primary contributors to classification. The developed deep-learning model shows significant potential not only in detecting choroidal metastases but, more importantly, in predicting their primary cancer origins from UWFP images. This capability could serve as a valuable adjunct in clinical decision-making by guiding more targeted and efficient systemic evaluations, particularly in patients with undiagnosed primary cancers.

Uveal melanoma is the most common malignant primary intraocular tumor in adults, associated with high mortality. Pediatric uveal melanoma generally has a more favorable course. However, when metastasis occurs, therapeutic options are limited. Clinical presentation, treatment, and outcome of children with uveal melanoma diagnosed in Germany and Austria between 2013 and 2024 were analyzed. Since 2013, 12 children were diagnosed with uveal melanoma in Germany and Austria-nine in the choroid, three in the ciliary body, and iris. Treatment comprised enucleation (five patients), external beam radiation with protons (two patients), ocular brachytherapy (four patients), and endoresection (one patient). Two patients developed metastasis. A 17-year-old male with liver metastasis died 30months after diagnosis. A 3-year-old male with metastatic choroidal melanoma presented with metastasis 6months after enucleation. Chemotherapy followed by nivolumab and ipilimumab led to a complete response. However, immunotherapy caused insulin-dependent diabetes mellitus. Genetic testing revealed a pathogenic constitutional TP53 variant, confirming Li-Fraumeni syndrome (LFS). At 24months after diagnosis of metastatic disease, he remains in complete response. This report underscores the rarity and diverse presentation of pediatric choroidal melanoma. Diagnosis of LFS in one patient highlights the importance of genetic testing for tumor predisposition and personalized approaches in managing rare pediatric tumors.

To evaluate the efficacy of the treatment of choroidal metastasis with combined photodynamic therapy (PDT) and intravitreal bevacizumab (IVB) and compare it with PDT alone. Retrospective analysis of 41 choroidal metastatic tumors: 19 tumors (13 patients) treated with PDT + IVB versus 22 tumors (8 patients) treated with PDT alone between 2011 and 2023. Outcomes measured included best-corrected visual acuity, tumor dimensions, central macular thickness, and subretinal fluid at baseline, 6 weeks, and final follow-up. With median follow-up of 7 (range: 3-84) months, the PDT + IVB group showed significantly better outcomes than the PDT alone group: improved best-corrected visual acuity at 6 weeks and final visit ( P = 0.02), higher complete subretinal fluid resolution at 6 weeks (68% vs. 27%, P = 0.002), and significant decrease in tumor thickness at both timepoints ( P = 0.04 and P = 0.004). The PDT alone group showed no significant change in tumor thickness. Tumor control rates (defined by fluid resolution and decreased thickness) were superior in the PDT + IVB group at 6 weeks (73.3% vs. 26.6%, P = 0.009) and final visit (92% vs. 47%, P = 0.01). This first series using combined PDT + IVB for choroidal metastasis demonstrates superior early and long-term functional and anatomical outcomes compared with PDT alone, suggesting it as a more effective management approach.

Abstract Introduction/Objective Choroidal metastasis from endometrial cancer is extremely rare. Its clinical presentation can mimic choroidal melanoma, the most common primary intraocular neoplasm. We describe the first reported fine needle aspiration cytology diagnosis of ocular metastasis from endometrial cancer. Methods/Case Report A 60-year-old female with history of metastatic endometrial endometrioid adenocarcinoma status post hysterectomy, chemoradiation, and immunotherapy, presented to ophthalmology with a right eye choroidal lesion. The initial clinical differential included primary uveal melanoma versus metastasis, and observation was recommended. Upon follow-up, the lesion had grown and was clinically favored to be choroidal melanoma. The patient underwent plaque brachytherapy and fine needle aspiration biopsy. Review of the aspirate cytospin slides revealed crowded cohesive groups and single atypical epithelioid cells exhibiting nuclear hyperchromasia, irregular nuclear membranes, and scant dense to focal possibly vacuolated cytoplasm. Immunohistochemistry showed the atypical cells were positive for PAX8 and ER, and were negative for SOX-10, supporting the diagnosis of metastatic endometrial carcinoma. Results n/a Conclusion Ocular metastasis is an uncommon clinical and pathologic diagnosis, and a clinical impression favoring primary ocular neoplasm can be misleading. This case emphasizes the importance of maintaining a broad differential diagnosis during cytologic evaluation and immunohistochemical workup of suspicious choroidal lesions in patients with underlying malignancy.

Cell-free DNA (cfDNA) has emerged as a useful liquid biopsy biomarker with many translational applications in oncology. Here, we review the uses of blood-based cfDNA in ophthalmic oncology, with a focus on uveal melanoma, retinoblastoma, conjunctival tumors, choroidal metastases, indeterminate choroidal lesions, and ocular histiocytosis. A systematic literature search in MEDLINE, PubMed, Web of Science, and Scopus from October 2017 to June 2025 was performed. Data extraction included tumor diagnosis, number of patients in the cohort, characteristics of the blood-based cfDNA assay employed (including technology used for mutation identification), number and types of genes analyzed, performance metrics for the assay, and any clinical impact. The use of blood-based cfDNA in the field of ophthalmic oncology has been studied to varying degrees. Perhaps its most well-researched area is uveal melanoma, in which applications for both primary and metastatic uveal melanoma continue to be evaluated. Its use in retinoblastoma has been investigated by a small number of groups. There is minimal but intriguing work on the use of blood-based cfDNA in for conjunctival tumors, choroidal metastases, tumors of indeterminate origin, and ocular histiocytosis. cfDNA science bridges the gap between basic research and clinical care. Within the field of ophthalmic oncology, cfDNA may be useful as a diagnostic/prognostic tool, for surveillance of metastatic or minimally residual disease, to identify driver mutations for treatment selection, as a biomarker of treatment response, for screening for recurrent or new cancer, and to detect new molecule clones.

To highlight the important role of multimodal ophthalmic imaging in establishing the diagnosis of choroidal metastasis. Case series of choroidal metastasis encountered in Universiti Malaya Medical Center between 2021 and 2023. Three patients with known cases of primary cancer were presented with choroidal metastasis. Two patients reported blurred vision, with a visual acuity of hand movement, while one patient remained asymptomatic with a visual acuity of 6/6. Fundoscopic findings including subretinal mass and exudative retinal detachment. B-scan ultrasonographic findings including diffuse, plateau, heterogenous choroidal lesion and dome-shaped choroidal mass. Classical optical coherence tomography (OCT) feature is lumpy bumpy choroidal appearance with subretinal fluid. Fundus fluorescein angiography (FFA) generally showed early hypofluorescence followed by heterogenous leakage in the late. Indocyanine green angiography (ICGA) showed absence of choroidal vessels overlying the choroidal lesion. From our case series, all patients with known case of primary cancer presented with choroidal metastasis, although rare, is the most common form of intraocular tumours. A detailed medical history, comprehensive clinical examination, and the use of multimodal ophthalmic imaging are essential for the accurate diagnosis of choroidal metastasis.

The objective is to differentiate choroidal metastases (CM) arising from various primary cancer sites based on clinical presentation and imaging. A retrospective, observational study of 67 eyes (58 patients). The mean age at presentation was 60 years (range, 29-83 years). At presentation, 37 patients (64%) with CM had a known primary systemic cancer, whereas in 21 patients (36%) CM was the first manifestation of systemic cancer. Overall, the primary cancer sites were lung (n = 32, 55%), breast (n = 12, 21%), gastrointestinal tract (n = 6, 10%), genitourinary tract (n = 3, 5%), and others (n = 5, 9%). Most choroidal lesions were creamy yellow in color (84%), while 5 eyes (7%) displayed orange-colored lesions secondary to lung neuroendocrine tumors. On multimodal imaging, A-scan showed medium-high internal reflectivity in 35 eyes (69%), and medium-low reflectivity in 16 eyes (31%). Fundus fluorescein angiography (FFA) demonstrated late hypofluorescence in 17 eyes (94%), whereas indocyanine green angiography (ICG) demonstrated hypofluorescence throughout all phases in 11 eyes (69%). Optical coherence tomography (OCT) showed the presence of a lumpy-bumpy choroid with compression of the overlying choriocapillaries (n = 52, 91%), subretinal fluid (n = 40, 75%), and hyperreflective foci (HRF) (n = 25, 47%). Factors such as right eye involvement, orange tumor, the presence of HRF, increased tumor thickness, CM as the first presentation, and a shorter interval between diagnosis of primary cancer and CM were found to be strongly correlated with the origin of primary cancer from the lung compared with breast (P < 0.05). Ancillary imaging along with clinical presentation can provide clues to the origin of CM from various cancer sites, thereby aiding in the early diagnosis, staging, and treatment of primary cancer. CM from lung cancer is more likely to precede the diagnosis of a primary tumor than breast metastases.

Simultaneous Retinal and Choroidal Metastases in Breast Cancer.

Uveal melanoma is a common primary intra-ocular malignancy in adults. It is a highly aggressive cancer that can spread to other regions of the body. Thus, early detection and appropriate treatment are critical for patient survival. Currently, we cannot imagine modern oncological diagnostics without positron emission tomography/computed tomography (PET/CT). Although PET/CT is commonly used in cancer care, it is not widely used for eye cancer. However, as technology advances, more eye specialists are using PET/CT to stage tumors before treatment, to predict how patients will respond to treatment, and to monitor their progress to assess treatment effectiveness. In this review, we cover the aspects of this technology in managing posterior uveal melanoma and describe the advantages of PET/CT in providing better information about tumors and their responses to applied treatment. We also describe the role of PET/CT in distinguishing among posterior uveal melanomas, benign lesions such choroidal nevus, and other primary or metastatic intra-ocular malignancies. We also discuss the role of PET/CT in staging metastatic choroidal melanoma. As technology continues to evolve, the role of PET/CT in comprehensive management of eye cancer is likely to expand, offering enhanced insights into tumor characteristics and treatment outcomes. This article reviews the role of PET/CT in diagnosing, staging, and monitoring treatment outcomes in patients with primary posterior uveal (choroidal and ciliary body) melanoma.

Purpose: The objective of this study was to evaluate the implementation of a Multidisciplinary Tumor Board (MDTB) strategy in the treatment of patients with uveal melanoma. Methods: A retrospective analysis was conducted on the implementation of MDTB meetings over a 24-month period. During this time, 72 intraocular tumors were discussed, including 59 confirmed cases of uveal melanoma. The MDTB involved a core group of specialists (e.g., ophthalmologists, oncologists, and radiologists), with other experts included when clinically appropriate. To assess patient satisfaction with the MDTB approach, a structured questionnaire was administered, including items on clarity of communication, perceived quality of care, and overall satisfaction, which were ranked on a 5-point scale. Results: A total of 319 patients with ocular, periocular, or orbital tumors were discussed during the study period, of which, 72 had intraocular tumors. A total of 13 (18%) were diagnosed to have choroidal metastases, whereas 59 (82%) had uveal melanomas. The average time between patient care and MDTB discussion was 15.9 days (IQR: 7.5-16.5). The mean time between the case discussion and the implementation of recommendations (diagnostic, therapeutic, or referral decisions) was 14.8 days (IQR: 6.0-23.75). Overall, 4 (7%) patients were classified as Stage I, 16 (27%) as Stage IIa, 18 (31%) as Stage IIb, 7 (12%) as Stage IIIa, 2 (3%) as Stage IIIb, and 12 (20%) as Stage IV. Regarding the satisfaction questionnaire, all patients (100%) agreed to have the clinical case discussed at the TB even though this could result in a delay in diagnostic/therapeutic implementation. However, only 60% of patients perceived they had been directly involved in the decision-making process. Conclusions: In selected cases of uveal melanoma and other types of cancer, MDTBs should be recognized as a gold standard in cancer care, allowing for comprehensive decision-making that draws on a wide range of highly specialized expertise.

Circumscribed choroidal hemangioma (CCH) is a rare vascular benign tumour of the choroid that typically presents as a solitary red-orange mass within the posterior pole in middle-aged adults with clinical symptoms of progressive vision loss, floaters, metamorphopsia and field defects. Despite its benign nature, it can present with complications, including subretinal fluid (SRF), serous detachment, cystoid macular oedema, and, in chronic cases, retinoschisis, retinal pigment epithelium changes, and neovascular glaucoma. Choroidal metastasis and choroidal melanoma have a close resemblance to choroidal haemangioma, which leads to a diagnostic dilemma. Imaging tools such as ultrasonography, optical coherence tomography, optical coherence tomography angiography, fluorescein angiography and indocyanine green angiography aid in the diagnosis making. Treatment aims to decrease exudation and thereby improve visual acuity in symptomatic patients. Photocoagulation, radiation therapy, photodynamic therapy (PDT), transpupillary thermotherapy (TTT), oral beta blockers and anti-vascular endothelial growth factor (VEGF) therapy are the available treatment options. In our case, we report a patient of circumscribed peripapillary choroidal hemangioma managed with a combined approach-based treatment using intravitreal anti-VEGF and oral beta blocker therapy. Due to its close proximity to the optic nerve of CCH, its treatment poses a challenge. Our case illustrates how a combined approach facilitates the successful management of the lesion.

Purpose: To report the use of Gamma Knife stereotactic radiosurgery in the treatment of refractory uveal effusion in the setting of choroidal metastasis and checkpoint inhibitor therapy. Methods: Review of a case of metastatic bronchial neuroendocrine carcinoma to the choroid that developed refractory unilateral uveal effusion after checkpoint inhibitor therapy initiation. Results: A 47-year-old Caucasian female with stage T1bN3M1 bronchial neuroendocrine carcinoma metastatic to the brain and stage 1A, grade 1 endometrial carcinoma status post hysterectomy was referred to the retina service for evaluation of a choroidal mass identified in brain MRI. Two weeks after starting atezolizumab, vision declined to 20/200 with new serous uveal effusion solely in the left eye. Systemic therapy was continued as it was life-prolonging, but the uveal effusion was refractory to topical and periocular corticosteroids. Gamma Knife stereotactic radiosurgery was delivered to the left choroidal metastasis, with resolution of the uveal effusions within 2 weeks. The patient completed her last cycle of atezolizumab, vision remained stable, and no new effusions were noted 1 month after radiotherapy. Conclusion: Checkpoint inhibitor-associated uveal effusion can occur in eyes with intraocular metastases, presumably due to a crosstalk between the tumor microenvironment and the immune system. Gamma Knife radiotherapy to solitary choroidal metastases may aid in rapid resolution of refractory uveal effusions, especially in patients who cannot stop the life-prolonging treatment.

Swept-source optical coherence tomography features of choroidal tumors and tumor mimics: A 5-year retrospective study.