2.2 Fundus Tumours

Examination Structure

1. Visual Acuity, IOP, Inspection, ± Refraction

(see 2 Posterior Segment General Comments)

  • Always ask for the VA and IOP (may be raised by melanocytic glaucoma, metastatic infiltration of the angle)
  • Look for ocular melanocytosis (higher risk of developing uveal melanoma)
  • Look for a port-wine stain (nevus flammeus) in Sturge Weber Syndrome
  • Look elsewhere for concurrent treatment of systemic cancers in ocular / orbital metastasis e.g. port-a-cath
  • Look for features of orbital invasion of the tumour e.g. proptosis, erythema

2. Anterior Segment & Anterior Vitreous

(see 2 Posterior Segment General Comments)

  • Look for iris heterochromia (often more obvious without the slit lamp) in iris tumours
  • A ciliary body melanoma may present with a sectoral fullness of the iris, ectopia lentis or be seen macroscopically in the anterior vitreous

3. Fundus Tumour Features

  • Is there a posterior vitreous detachment? (Weiss ring)
  • If the view is hazy, there may be:
    • Vitreous haemorrhage (the location of dense haemorrhage may help localise the site of bleeding) or
    • Vitritis (look for a “headlight in a fog” suggesting toxoplasmosis chorioretinitis)

Location

  1. Determine quadrant and the distance from the optic disc and fovea
  2. A lesion near the macula will usually be more visually threatening, although some lesions (e.g. retinal capillary haemangioblastomas) can cause distant macular oedema

Size (Base)

  1. Smaller, posterior lesions can be measured in disc diameters. Larger anterior lesions are best measured in
  2. Millimetres. The distance across the fundus image viewed with a Pan Retinal 2.2. BIO lens is 14mm

Focality

  1. Multiple choroidal masses could suggest metastatic disease or BDUMP

Colour

  1. Pigmented (most naevi, melanomas). CHRPE and melanocytomas tend to be jet black
  2. Hypopigmented (metastases, choroidal osteoma, metastases)
  3. Orange (choroidal hemangiomas tend to have a similar colour to the surrounding fundus)
  4. Remember that tumours can have mixed pigmentation

Depth

  1. Confirm the depth of the tumour relative to the retina and choroid.
  2. A choroidal lesion will have retinal vessels coursing over it.
  3. The thickness of the choroidal tumour can also later be objectively determined on B scan or EDI-OCT (if shallow enough)

Other Features

  1. Look for subretinal fluid, orange pigment (melanoma) and lacunae (CHRPE)

4. Posterior Pole & Peripheral Retina

Compare the overall colour of the fundus. A hyperaemic “tomato catsup / ketchup” fundus suggests Sturge Weber Syndrome and a hyperpigmented fundus suggests ocular melanocytosis.

Any choroidal tumour can present with the following:

  1. CNV (haemorrhage, lipid, fluid)
  2. Subretinal fluid / exudative retinal detachment (when chronic this causes RPE changes)
  3. Retinal atrophy
  4. Cystoid macular oedema

Also check the optic disc for glaucoma (e.g. Sturge-Weber Syndrome, melanolytic glaucoma) and melanocytomas

          

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