Case Report of a Very Rare and Interesting Case Report of Choroidal Melanoma Presenting as a Case of Acute Congestive Glaucoma Left Eye in a 55 Years Male

As mentioned before the ch melanomas have atypical presentations which are as follows

A. Can be ant to lens

B. Involve angle of filtration

C. Involve vitreous

D. Sometimes severe ocular pain may be the only presentation

E. Very rarely the presentation may be sever fatigability Loss of weight and appetite and loss of bladder control if they are ant to lens the clinical presentation is

I. Blurred vision

II. Progressive and painless visual field loss

III. Paracentral scotoma

If angle of filtration is involved the clinical presentation is

A. A c glaucoma

B. A a c glaucoma

C. Sec glaucoma

D. Ocular hypertension

E. Low tension glaucoma

F. Normal tension glaucoma

G. Pigmentory glaucoma

H. Neovascular glaucoma

If vitreous is involved the clinical presentation is vitreous floaters treatment if the tumor is

i. 1 less than 12mm observation

ii. If more than 12mm enucleation

iii. Plaquebracopexy

iv. Radiotherapy

v. Chemotherapy

vi. Block section

vii. Pan retinal photocoagulation

viii. Pars plana vitrectomy

ix. Sometimes one may have to do exenteration

In 2011 a 55 years male patient presented with acute onset of sever left eye pain marked redness and sudden loss of vision it was a typical presentation of a c g glaucoma for which he received treatment from an emergency ophthalmological dept of medical college hospital in the form of 1 topical prostaglandin with

a. Timilol eye drops once

b. Dorzolamide with timilol eye drops twice

c. Topical steroid drops 4 times

d. Iv 500mg acetazolamide

e. Iv 500cc of 20 percent mannitol

However even after 8 to 10 hours of this medication pt did not show any improvement in his signs and symptoms however no b scan ultrasound left eye was done he was advised admission which was refused by him later he consulted other ophthalmologist for second opinion who performed b scan ultrasound and it showed a solid retinal detachment MRI scan brain was done for confirmation of choroidal melanoma but to the ill luck of both patient and ophthalmologist even after repeating the MRI the report was very unsatisfactory this created lot of confusion and pt started going from one ophthalmologist to other he was in this untreated stage for a period of 2 years i saw pt in 2013 left eye opaque media making the details of post segment difficult to visualize i performed b scan picked up solid retinal detachment MRI brain confirmed the radiological evidence of choroidal melanoma it also revealed normal optic nerve optic tract chiasma and radiatiobs also basal gangla were normal pituitary fossa and gland normal midbrain thalamic ventricles and cerebral hemispheres were normal ultrasound liver normal so on all these reports under g a i did block section by removing all the intraocular contents like cornea lens vitrous choroid and retina leaving behind iscleral cavity all extra ocular muscle attachments and underlying orbital adenexathe removed tissues were sent for histo pathological examination which did not reveal any evidence of malignancy in stitched the ant and post lips of sclera with 6 zero vicoryl kept a corrugated ruber drain in the intrascleral cavity for drainage of any secretions the drain was removed after 24 hours later i put a confirmer to increase the orbital volume the confirmer was removed after 15 days later a well fitting and well matching prosthesis was put by me in left socket [1-8].

More than 4 years have passed pt is doing very well he is pain free and cosmetically he has a well fitting left eye prosthesis his repeat MRI brain is normal so is his ultrasound liver [9-15].

In conclusion we come to one important point that is if we come across a case of a c glaucoma which does not respond to treatment please do b scan ultrasound and MRI respectively and accordingly do the necessary treatment to support this statement i will put forward following

A. In institute of ophthalmology manchester London a pt choroidal melanoma presented as a c glaucoma did not respond to usual Anti-glaucoma medication the vision in other eye was 6 18 unaided pt did not respond to anti glaucoma medication MRI brain revealed choroidal melanoma so enucleaton was done.

B. In bascom palmar institute of ophthalmology university of miami florida 2 pts of choroidal melanomas presented with AAC glaucoma one pt was put on antiglucoma medication and later laser iridotomy was done the 2nd pt had hazy media making details of post segment difficult to be visualized giving a strong evidence od ocult intra ocular melanoma b san and MRI were done which proved the diagnosis of ch melanoma so enucleation was done.

C. Sometimes choriodal melanoma may present as sec glaucoma in this context in university of cario dept of ophthalmology and pathology published in Saudi medical journal a pt of choroidal melanoma presented as sec glaucoma with an i o pof 56mm hg did not respond to treatment MRI brain revealed choroidal melanoma so enucleation was done.

D. Malignant melanoma of ciliary body can present as ocular hypertension or chronic uvitis however this tumor yields poor results [15-19].

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