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JAMA Ophthalmology Clinical Challenge
October 24, 2019

An Orbital Lesion Diagnosed on Routine Fundus Examination

Author Affiliations
  • 1Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
JAMA Ophthalmol. 2019;137(12):1456-1457. doi:10.1001/jamaophthalmol.2019.4106

A man in his 80s with pseudophakia presented for routine follow-up of an elevated choroidal nevus in his right eye. His medical history was notable for stage III non-Hodgkin follicular lymphoma in the hilar and axillary nodes, which was asymptomatic and actively monitored by oncology, prostate cancer treated surgically that was in remission, and atrial fibrillation managed with medication (digoxin and warfarin). The choroidal nevus had been observed for the past 2 years; ultrasonography from 2 years prior revealed dimensions of 1.9 (height) × 9.3 (base) mm with medium internal reflectivity. There were no other concerning features noted, such as orange pigment or associated subretinal fluid.

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    1 Comment for this article
    Regarding Diagnosis and Management
    Surbhi Agrawal, MBBS, MD | All India Institute of Medical Sciences
    It is with great interest that I read this Clinical Challenge.

    The authors' choice of going ahead with orbital imaging seems to be the most appropriate action in this case. However, one cannot help wonder why the orbital imaging was not performed as soon as the mass was noted on B-scan ultrasonography.

    If the authors could provide insight about why the imaging was postponed to 3 weeks till the patient actually developed proptosis, it would add value to the discussion.

    Development of a new mass in a patient on regular follow up that leads to development
    of significant proptosis within 3 weeks suggests a fairly rapidly growing mass. In such a scenario it would not be unnatural to expect pressure effects on the globe in not so far a time in the future. Hence, a brief commentary on the reasons leading to the patient and the team's decision to not pursue any further treatment would also be of great value.