Choroidal Melanoma
What Is Choroidal Melanoma
Choroidal melanoma is a cancerous tumor that develops from pigment-producing cells called melanocytes within the choroid, the vascular layer beneath the retina. Learning about how this tumor forms and who it affects can help patients recognize its significance.
The choroid is a thin layer of blood vessels that supplies oxygen and nutrients to the outer retina. Melanocytes, the same cells responsible for skin pigmentation, are present throughout the choroid. When these cells undergo malignant changes and begin to grow in an uncontrolled manner, a choroidal melanoma forms. The tumor typically appears as a dome-shaped or mushroom-shaped mass on the back wall of the eye and can range in size from small to very large.
A choroidal nevus is a benign pigmented spot in the choroid, sometimes described as a freckle inside the eye. Most choroidal nevi remain stable and harmless, but a small percentage can transform into melanoma over time. Distinguishing between a benign nevus and an early melanoma is one of the most important tasks our retina specialists perform, using detailed measurements, imaging, and established risk-factor guidelines such as the TFSOM (To Find Small Ocular Melanoma) mnemonic.
Choroidal melanoma is most frequently diagnosed in adults between the ages of 50 and 80, though it can occur at any age. People with lighter skin, light-colored eyes, and those of European descent have a higher incidence. Other risk factors include the presence of ocular melanocytosis (a condition causing increased pigmentation in and around the eye), a personal or family history of uveal melanoma, and certain genetic predispositions such as BAP1 mutations. Unlike skin melanoma, ultraviolet light exposure has not been conclusively linked to choroidal melanoma.
Symptoms and Diagnosis
Many choroidal melanomas are discovered during routine dilated eye examinations before a patient notices any symptoms at all, which underscores the importance of regular eye screenings.
Small choroidal melanomas often produce no symptoms. As the tumor grows, it may cause blurred or distorted vision, a visual field defect (a shadow or missing area in one's side vision), flashing lights, or new floaters. In some cases, the tumor causes fluid to accumulate beneath the retina, leading to a secondary retinal detachment that further compromises vision. Any sudden or progressive change in vision, particularly in one eye, warrants a prompt evaluation.
When a suspicious lesion is identified, our retina specialists employ several imaging techniques to characterize the tumor. Ocular ultrasound (B-scan) measures the height and shape of the mass and can reveal the classic low-to-medium internal reflectivity pattern typical of melanoma. Optical coherence tomography (OCT) helps evaluate associated retinal changes such as subretinal fluid. Fundus photography and autofluorescence imaging document the lesion's appearance, orange pigment (lipofuscin) on the tumor surface, and proximity to the optic nerve and macula.
Fluorescein angiography and indocyanine green angiography can reveal abnormal blood vessel patterns within the tumor. In select cases, fine-needle aspiration biopsy may be performed to confirm the diagnosis and obtain tissue for genetic testing. A systemic workup, typically including liver imaging with MRI or CT, is recommended because the liver is the most common site of metastasis from uveal melanoma.
Treatment Options for Choroidal Melanoma
Treatment depends on the tumor's size, location, and whether there is evidence of spread beyond the eye. Our retina specialists work closely with ocular oncologists and radiation specialists to develop an individualized plan for each patient.
Plaque brachytherapy (also called plaque radiotherapy) is the most widely used treatment for small-to-medium choroidal melanomas. A small, disc-shaped shield containing radioactive seeds is surgically sutured to the outer wall of the eye directly over the tumor. The plaque delivers a concentrated dose of radiation to the tumor over several days, after which it is removed in a second brief procedure. This eye-conserving approach achieves tumor control rates above 90 percent for eligible tumors while preserving the eye and, in many cases, useful vision.
Proton beam therapy is an alternative form of radiation that delivers highly focused energy to the tumor while minimizing damage to surrounding healthy tissue. It is particularly useful for tumors near the optic nerve or macula where precision is critical. Treatment is typically delivered over several sessions at a specialized proton therapy center. Tumor control rates with proton beam radiation are comparable to those of plaque brachytherapy.
For very large tumors, tumors that have caused extensive damage within the eye, or cases where vision cannot be salvaged, enucleation (surgical removal of the eye) may be recommended. While the prospect of losing an eye is understandably difficult, enucleation can be a life-preserving decision when the tumor is too advanced for radiation-based treatments. After surgery, patients are fitted with a custom ocular prosthesis that closely matches the appearance of the other eye.
Transpupillary thermotherapy (TTT) uses infrared laser energy to heat and destroy small tumors and is sometimes combined with plaque brachytherapy as an adjunct treatment. Surgical resection, in which the tumor is physically removed while preserving the eye, is performed at select centers for certain medium-to-large tumors. Observation may be appropriate for very small, indeterminate lesions that have not yet shown definitive signs of growth or malignancy, with close monitoring at regular intervals.
Prognosis and Long-Term Monitoring
Understanding the outlook after a choroidal melanoma diagnosis involves consideration of both local tumor control and the risk of metastatic disease. Ongoing follow-up care plays a central role in long-term management.
Several features help predict how a choroidal melanoma may behave over time. Larger tumor size (particularly thickness greater than 10 mm or diameter greater than 15 mm), involvement of the ciliary body, extraocular extension, and certain cell types (epithelioid cells carry a higher risk than spindle cells) are associated with a less favorable prognosis. Genetic testing of tumor cells, specifically analysis of chromosome 3 status and gene expression profiling (such as the DecisionDx-UM test), has become an important tool for estimating metastatic risk. Loss of one copy of chromosome 3 (monosomy 3) and a Class 2 gene expression profile indicate a significantly higher risk of metastatic spread.
Because choroidal melanoma can spread to distant organs, particularly the liver, ongoing systemic surveillance is recommended. Patients typically undergo liver imaging (ultrasound, MRI, or CT) along with blood work at regular intervals, often every six to twelve months, depending on their risk profile. Early detection of metastatic disease is important because emerging treatments, including immunotherapy and liver-directed therapies, may offer improved outcomes compared to historical options.
The impact on vision depends on tumor size, location relative to the macula and optic nerve, and the type of treatment received. Some patients retain good functional vision following plaque brachytherapy or proton beam therapy, while others experience gradual vision decline due to radiation effects on the retina or optic nerve over the months and years following treatment. Our retina specialists continue to monitor treated eyes with dilated examinations, OCT, and ultrasound to detect and manage complications such as radiation retinopathy, cystoid macular edema, or neovascular glaucoma.
Frequently Asked Questions
No. Although both arise from melanocytes, choroidal melanoma (a type of uveal melanoma) differs from cutaneous (skin) melanoma in its genetic drivers, metastatic patterns, and treatment approaches. Uveal melanoma tends to spread to the liver, whereas skin melanoma more commonly spreads to lymph nodes and lungs. The immunotherapy drugs that have transformed skin melanoma treatment have shown more limited success in uveal melanoma, though newer agents such as tebentafusp have shown benefit for certain patients with metastatic uveal melanoma.
Yes. Many choroidal melanomas are first spotted during a routine dilated eye examination, often before the patient has any symptoms. This is one of the reasons we recommend regular comprehensive eye exams, particularly for adults over 40. A dilated exam allows your eye doctor to view the entire retina and choroid, increasing the chance of catching a lesion early when treatment options are broadest.
The plaque is typically placed during a short outpatient surgical procedure and left in position for three to seven days, depending on the prescribed radiation dose. Patients may be sent home during the treatment period with the plaque in place. A second brief procedure removes the plaque once treatment is complete. Most patients can return to normal activities within a week or two after the plaque is removed.
Not necessarily. The majority of patients with small-to-medium tumors are treated with eye-conserving radiation therapies such as plaque brachytherapy or proton beam radiation. Enucleation is generally reserved for very large tumors or situations where the eye has already lost functional vision. Your treatment team will discuss all available options and help determine the approach that offers the best balance of tumor control and quality of life.
Genetic testing performed on a biopsy sample of the tumor can help predict your risk of metastatic disease. Tests evaluate chromosome 3 status and gene expression profiles to classify tumors into lower-risk and higher-risk categories. This information does not change the treatment of the eye itself, but it guides how frequently and intensively you should be monitored for spread to other organs, and it can help you and your oncology team plan ahead.
Most patients are seen frequently in the first year after treatment, typically every three to four months, for dilated eye exams and imaging to confirm the tumor is responding. Visits are then gradually spaced to every six months and eventually annually for long-term surveillance. Systemic monitoring, including liver imaging, continues on a parallel schedule tailored to your individual risk profile. Many patients remain under lifelong follow-up.
What our Patients say
4.8
Reviews
(3,408)