A 59-year-old female patient was referred for left eye enucleation (LE) with a presumptive diagnosis of choroidal melanoma located at the superior temporal level.
No personal pathological history or family history of importance.
Visual acuity of right eye (OD) 1 and left eye, the anterior segment, without particularities, ocular pressure: RE 15 and LE 23 mmHg.
In the posterior segment there is evidence of a hyperpigmented tumor, located at the superior temporal level, with variable coloration in the dark brown with areas of hemorrhage on its surface, subretinal fluid around and mild vitreous.
Medium fluoresceinography (AFG) was performed on the fundus examination of the fundus, revealing a neovessel over the surface and a dye leakage in late times at the base of the lesion.
Clinical and oncological examinations were negative to rule out primary or metastatic cancer focus.
With the data obtained, the clinical and echocardiographic diagnosis of choroidal melanoma was presumed.
The patient preferred conservative treatment, performing choroidectomy (partial lamellar sclerectomy) under general hypotensive anesthesia.
The postoperative course was good.
No local or systemic recurrences were observed during the 9-month follow-up.
The surgical specimen was studied with Hematoxylin-Eosin, Trichromycosis, PAS and immunohistochemistry (S-100 protein, vimentin, Melan-A and HMB45).
Histopathological study revealed the presence of an intensely pigmented tumor with characteristics of choroid hyperplasia.
Immunohistochemical studies were positive for S-100 protein and vimentin, and negative for Melan-A and HMB45.
After pigmentation with 5% authenticated water, in different sections to be able to apply the solution for different periods (24, 48 and 72 h), the classic clear cytoplasm cells, with typical "non-compliance" nuclei, were clearly observed.
