Simultaneous metastases of cutaneous malignant melanoma to conjunctiva and choroid

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Abstract
A 42 year old white man presented with a history of a small superficial black mark in the temporal aspect of the right eye, which had increased in size for the past 2 months. There was no significant ocular history. Two years earlier he had had a large malignant melanoma, 4.5 × 3.5 cm, removed from his lower back. On histopathology, this had been diagnosed as a superficial spreading type (Clarke's level IV with Breslow thickness of 3.5 mm). The mitotic count was 5 per 10 high power field (HPF) with a sparse lymphocytic infiltrate seen at the edges. It had been excised completely with no vascular or lymphatic invasion seen in the section. He had been thoroughly screened and a computed tomograph (CT) scan of the abdomen and head had not revealed any metastases. Subsequently, he had been followed up on a 4 monthly basis over the next 2 years and no recurrences had been found. During this period he developed a severe form of asthma which was controlled by oral prednisolone 25 mg per day. He otherwise felt well and on examination seemed to be in good general health. An enlarged lymph node was found in his left axilla. Visual acuity was 6/6 in the right eye and 6/5 in the left eye. Examination of the anterior segment in the right eye revealed a small superficial blackish brown mark about 3 mm in size on the lateral aspect of the bulbar conjunctiva. Left eye anterior segment examination was normal. The intraocular pressure was 17 mm Hg in both the eyes. Fundus examination of both the eyes revealed multiple, widespread, irregular subretinal pigmented deposits (Fig 1), some flat and some slightly elevated. There was no associated cataract or retinal detachment. His creatinine levels were found to be raised at 253 μmol/l, urea at 14.5 mmol/l, and lactate dehydrogenase at 443 IU/l. Urine examination showed both blood and protein present.

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