2.2 Fundus Tumours
Examination Structure
(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
(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
- 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
- Determine quadrant and the distance from the optic disc and fovea
- 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)
- Smaller, posterior lesions can be measured in disc diameters. Larger anterior lesions are best measured in
- Millimetres. The distance across the fundus image viewed with a Pan Retinal 2.2. BIO lens is 14mm
Focality
- Multiple choroidal masses could suggest metastatic disease or BDUMP
Colour
- Pigmented (most naevi, melanomas). CHRPE and melanocytomas tend to be jet black
- Hypopigmented (metastases, choroidal osteoma, metastases)
- Orange (choroidal hemangiomas tend to have a similar colour to the surrounding fundus)
- Remember that tumours can have mixed pigmentation
Depth
- Confirm the depth of the tumour relative to the retina and choroid.
- A choroidal lesion will have retinal vessels coursing over it.
- The thickness of the choroidal tumour can also later be objectively determined on B scan or EDI-OCT (if shallow enough)
Other Features
- Look for subretinal fluid, orange pigment (melanoma) and lacunae (CHRPE)
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:
- CNV (haemorrhage, lipid, fluid)
- Subretinal fluid / exudative retinal detachment (when chronic this causes RPE changes)
- Retinal atrophy
- Cystoid macular oedema
Also check the optic disc for glaucoma (e.g. Sturge-Weber Syndrome, melanolytic glaucoma) and melanocytomas
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