CLINICAL SCIENCES

Enhanced Depth Imaging Optical Coherence

Tomography of Small Choroidal Melanoma
Comparison With Choroidal Nevus
Carol L. Shields, MD; Swathi Kaliki, MD; Duangnate Rojanaporn, MD; Sandor R. Ferenczy, CRA; Jerry A. Shields, MD

Objective: To evaluate characteristics of small choroidal melanoma using enhanced depth imaging spectraldomain optical coherence tomography (EDI-OCT).
Design: Retrospective comparative analysis.
Results: Of 37 eyes with small choroidal melanoma im-

aged using EDI-OCT, the mean tumor thickness was 1025

m by EDI-OCT compared with 2300 m by ultrasonography. By EDI-OCT, choroidal features included optical shadowing in 36 (100%) and overlying choriocapillaris thinning in 37 (100%). Outer retinal features
included shaggy photoreceptors in 18 (49%), as well as
absence (structural loss) of photoreceptors in 9 (24%),
inner segmentouter segment junction in 24 (65%), external limiting membrane in 16 (43%), outer nuclear layer
in 6 (16%), and outer plexiform layer in 4 (11%). Inner
retinal features included irregularity of inner nuclear layer
in 3 (8%), inner plexiform layer in 3 (8%), ganglion cell
layer in 3 (8%), and nerve fiber layer in 2 (5%). Also identified were subretinal fluid in 34 (92%), subretinal lipofuscin deposition in 35 (95%), and intraretinal edema in
6 (16%). Using EDI-OCT, a comparison with similar-

Author Affiliations: Ocular

Oncology Service, Wills Eye
Institute, Thomas Jefferson
University, Philadelphia,
Pennsylvania.

sized choroidal nevus revealed that small choroidal melanoma showed increased tumor thickness, subretinal fluid,
subretinal lipofuscin deposition, and retinal pigment epithelium atrophy. Statistically significant EDI-OCT features for small choroidal melanoma included intraretinal edema (P = .003), shaggy photoreceptors or loss of
photoreceptors (P=.005), loss of external limiting membrane (P = .008), loss of inner segmentouter segment
junction (P = .02), irregularity of inner plexiform layer
(P=.04), and irregularity of ganglion cell layer (P=.04)
(t test and 2 test). Shaggy photoreceptors were found
overlying small choroidal melanoma in 18 (49%) but were
not observed overlying choroidal nevus (P .001).
Conclusions: Small choroidal melanoma tumor thick-

ness was overestimated by 55% on ultrasonography compared with EDI-OCT. The EDI-OCT features of small choroidal melanoma compared with choroidal nevus include
increased tumor thickness, subretinal fluid, subretinal lipofuscin deposition, and retinal irregularities, including shaggy photoreceptors.
Arch Ophthalmol. 2012;130(7):850-856

HE RECOGNITION OF SMALL

choroidal melanoma by
characteristic clinical features is critical to patient
survival.1 The smaller the
melanoma at detection and treatment,
the better is the life prognosis.2 In 1992,
Diener-West and coworkers3 reported that
5-year mortality after enucleation was 16%
for small melanoma, 32% for medium
melanoma, and 53% for large melanoma.
Shields and colleagues2 further emphasized the prognostic importance of tumor size and identified that each 1-mm increase in melanoma thickness added
approximately 5% increased risk for metastatic disease at 10 years. Based on these
and other findings, early detection of choroidal melanoma when the tumor is small
(3-mm thickness) is important.
The challenge in early detection of choroidal melanoma relates to its clinical simiARCH OPHTHALMOL / VOL 130 (NO. 7), JULY 2012
850

larity to benign choroidal nevus. Lesions

with 3-mm thickness or less can be particularly challenging to distinguish clinically. Differentiation rests on identification of ophthalmoscopically visible factors
(such as greater tumor thickness, the presence of subretinal fluid, and overlying lipofuscin), as well as the tumor margin near
the optic disc and the absence of drusen
and halo.4-7 Diagnostic testing can confirm these features using optical coherence tomography (OCT) for detection of
subretinal fluid and autofluorescence for
depiction of overlying changes in the retinal pigment epithelium (RPE) that are suggestive of lipofuscin accumulation.
Older versions of OCT provided information on retinal and RPE alterations overlying melanoma, but little detail was apparent within the tumor or surrounding
choroid.8-13 Recent improvements in enhanced depth imaging spectral-domain

WWW.ARCHOPHTHALMOL.COM

2012 American Medical Association. All rights reserved.

Downloaded From: http://jamanetwork.net/ on 01/08/2014

Curve 1

Curve 2
200 m

1000
821

Thickness, m

800
600
400
200
0
0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0

Figure 1. Evaluation of small choroidal melanoma by enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) and by ultrasonography.
A, Infrared photograph showing 7 vectors of an EDI-OCT image passing through a juxtapapillary choroidal melanoma. B, Measurement of choroidal tumor
thickness with curve 1 along the inner margin of the melanoma and with curve 2 along the outer margin of the melanoma. C, Measurement of choroidal melanoma
thickness from the apex to the base of the lesion by ultrasonography (yellow line). D, Optical coherence tomography caliper measuring the maximum choroidal
melanoma thickness between curves 1 and 2.

OCT (EDI-OCT) allow for better imaging of choroidal detail.14,15 For tumors, EDI-OCT provides in vivo quantification of tumor dimensions and cross-sectional detail of
the tumor and surrounding choroidal tissues that previously were not depicted. Herein, we report our experience with EDI-OCT in the assessment of small choroidal
melanoma. We explored the imaging features and tumor
thickness in 54 consecutive eyes with small choroidal melanoma and compared our results with the findings in similarsized choroidal nevus.
METHODS
A retrospective comparative study was designed to evaluate the
imaging characteristics of small choroidal melanoma vs choroidal nevus using EDI-OCT. All the patients who were diagnosed
as having small choroidal melanoma (3-mm thickness on ultrasonography) during a 1-year period between August 1, 2010,
and August 1, 2011, on the Ocular Oncology Service, Wills Eye
Institute, Philadelphia, Pennsylvania, and who were imaged with
EDI-OCT were included in this study. Clinical and imaging features of the small choroidal melanoma were evaluated. Wills Eye
Institutional Review Board approval was obtained.
The EDI-OCT was performed through a dilated pupil
(Heidelberg Spectralis HRAOCT; Heidelberg Engineering)
using accompanying acquisition and analysis software (version 5.3.3.0 with automated EDI). The axial resolution was 3.5
m, with an imaging speed of 40 000 A-scans per second. The
images were captured using a custom image acquisition protocol of up to 13 raster lines of 9-mm image length, with 1536
A-scans per line. Real-time eye tracking (TruTrack Active Eye
Tracking; Heidelberg Engineering) was used, and automatic realtime image averaging was set at 100 images. The EDI-OCT was
performed using a technique similar to that described by Spaide
et al,14 whereby the instrument is displaced closer to the eye to
obtain an inverted image, which is adjusted by software to visualize the choroidal detail in the upright position. An EDIOCT image was considered optimal and suitable for study when

both the anterior and posterior margins of the tumor and the
overlying retina were visualized. Images were classified as suboptimal when a portion of the tumor or the overlying retina
could not be visualized, and these were excluded from the study.
Patient demographic data included age, sex, and race/
ethnicity. Clinical tumor data included quadrantic location of
the tumor epicenter, tumor basal diameter (in millimeters), tumor margin to the foveola and optic disc (in millimeters), color
(pigmented, nonpigmented, or mixed), and related alterations in subretinal fluid, subretinal lipofuscin deposition, intraretinal edema, and RPE. The tumor thickness was measured by ultrasonography (in millimeters) and by EDI-OCT (in
micrometers).
Risk factors for growth1,4-6 of 37 small choroidal melanomas included tumor thickness greater than 2 mm in 28 (76%),
subretinal fluid in 34 (92%), symptoms of photopsia or visual
loss in 27 (73%), orange pigment in 36 (97%), tumor margin
within 3 mm of the optic disc in 32 (86%), hollowness on ultrasonography in 34 (92%), and the absence of overlying drusen in 33 (89%). Tumor growth (before referral) was documented in 6 (16%).
The EDI-OCT features included optical qualities of the melanoma and the status of surrounding tissues, including the choriocapillaris and large choroidal vessels, overlying RPE or Bruch
membrane, and retina. The retinal layers were evaluated for abnormalities from outer to inner retina. The presence of subretinal fluid, subretinal lipofuscin deposition, and intraretinal
edema was noted.
The method for measurement of the tumor thickness on EDIOCT involved the placement of a parabolic curve on the anterior (curve 1) and posterior (curve 2) tumor margins, with caliper cross-sectional measurement between the apex of the 2
curves (Figure 1). Curve 1 was produced by autosegmentation using OCT software automatically connecting positioned
points at the base of the RPE. Curve 2 was produced by manual
segmentation using manually positioned points at the tumor
base judged to be at the junction of the hyperreflective inner
sclera. If dense optical shadowing from the melanoma prohibited visualization of the tumor base for point selection and

ARCH OPHTHALMOL / VOL 130 (NO. 7), JULY 2012

851

WWW.ARCHOPHTHALMOL.COM

2012 American Medical Association. All rights reserved.

Downloaded From: http://jamanetwork.net/ on 01/08/2014

Table 1. Enhanced Depth Imaging Spectral-Domain

Optical Coherence Tomography of 37 Eyes With Small
Choroidal Melanoma
Value
(n = 37)

Variable
Patient Features
Age, y
Mean
Median (range)
Race/ethnicity, No. (%)
White
Nonwhite
Sex, No. (%)
Male
Female
Presence of symptoms, No. (%)
Visual acuity, No. (%)
20/40
20/40
Small Choroidal Melanoma Features
Color, No. (%)
Pigmented
Nonpigmented
Mixed
Location of melanoma epicenter, No. (%)
Macula
Extramacula
Distance from tumor margin to foveola, mm
Mean
Median (range)
Distance from tumor margin to optic disc, mm
Mean
Median (range)
Tumor basal diameter, mm
Mean
Median (range)
Ultrasonography findings
Tumor thickness, mm
Mean
Median (range)
Configuration, No. (%)
Plateau
Dome
Acoustic hollowness
Choroidal excavation

56
60 (10-92)
37 (100)
0
20 (54)
17 (46)
27 (73)
18 (49)
19 (51)

27 (73)
6 (16)
4 (11)
21 (57)
16 (43)
1
0 (0-5)
1.7
1.5 (0-6)
6.7
6 (3-13)

2.3
2.5 (1.7-3.4)
3 (8)
34 (92)
28 (76)
29 (78)

manual segmentation, autosegmentation by OCT software at

nearby visible points was used to produce curve 2. The spectraldomain OCT caliper was then used to measure the greatest distance between curves 1 and 2 as representative of choroidal tumor thickness.
Each eye was evaluated with diagnostic ophthalmic ultrasonography (Eye Cubed; Ellex) using a 10-mHz posterior segment sealed probe with movie capability, image acquisition rate
of 25 frames per second, adjustable gain from 27 to 90 dB, axial
resolution of 50 m, and lateral resolution of 100 m. Video
image capture using standard 2-dimensional high-resolution
B-scan was performed, and cross vector A-scan analysis was performed through the greatest tumor thickness. Two-caliper measurement of the greatest tumor thickness was performed from
the tumor apex to the tumor base.
Statistical analysis was performed using the t test and 2 test.
Commercially available software (SPSS 16.0; SPSS, Inc) was used
to compare the EDI-OCT features of choroidal melanoma with
previously described features of choroidal nevus.16

RESULTS

Of 54 eyes with small choroidal melanoma imaged using

EDI-OCT, the image quality was judged as optimal in the
37 eyes (69%) that were included in this study. Demographic and clinical features of the patients with small
choroidal melanoma are listed in Table 1. The mean patient age was 56 years, and patients as young as 10 years
and as old as 92 years were able to provide optimal
imaging. The small choroidal melanoma was located
within the macula in 21 eyes (57%) and outside of the
macula in 16 eyes (43%). The overall mean distance from
the tumor margin to the foveola was 1 mm.
The mean basal diameter of the small choroidal melanoma was 6.7 mm, and the mean thickness using ultrasonography was 2.3 mm (median, 2.5 mm; range, 1.73.4 mm). The latter values were converted to 2300 m
(median, 2500 m; range, 1700-3400 m). Using EDIOCT, the mean tumor thickness was 1025 m (median,
1019 m; range, 639-1410 m) (Table 2). The mean
difference of 1275 m (a 55% reduction) between the tumor thickness measurement by ultrasonography vs EDIOCT was statistically significant (P .001).
The EDI-OCT features of the small choroidal melanoma showed homogeneous optical reflectivity along the
anterior surface, with gradual shadowing more deeply.
The internal characteristics of the tumor were unresolvable. Optical shadowing was partial in 27 eyes (73%) and
complete in 10 eyes (27%). The overlying choriocapillaris was thinned in every eye. Bruch membrane showed
rupture in 1 eye (3%) and drusen in 4 eyes (11%). The
tumor, choroid, and Bruch membrane features did not
significantly differ from those of choroidal nevus (Table 2).
Features that were more often found with small choroidal melanoma compared with choroidal nevus included increased tumor thickness, subretinal fluid, subretinal lipofuscin deposition, and RPE atrophy (Figure 2).
Because these are established clinical features to classify
melanoma vs nevus, they were excluded from the statistical evaluation. Features on EDI-OCT that were significantly more often found with small choroidal melanoma
compared with choroidal nevus included increased shaggy
photoreceptors (P.001), abnormality of photoreceptors (P=.005), loss of external limiting membrane (P=.008),
loss of inner segmentouter segment junction (P=.02), intraretinal edema (P = .003), irregularity of inner plexiform layer (P=.04), and irregularity of ganglion cell layer
(P=.04).
COMMENT

Our understanding of normal choroidal anatomy and disease states continues to improve with EDI-OCT. In a seminal study, Spaide and coworkers14 found that the normal
subfoveal choroidal thickness by EDI-OCT is approximately 320 to 330 m. Subsequent studies15,17,18 disclosed that aging, refractive error, and disease could lead
to changes in choroidal thickness, ranging from decreased
thickness of 50 m in age-related macular degeneration
and myopia to increased thickness exceeding 500 m in
central serous chorioretinopathy. Margolis and Spaide15

ARCH OPHTHALMOL / VOL 130 (NO. 7), JULY 2012

852

WWW.ARCHOPHTHALMOL.COM

2012 American Medical Association. All rights reserved.

Downloaded From: http://jamanetwork.net/ on 01/08/2014

Table 2. Enhanced Depth Imaging Spectral-Domain Optical Coherence Tomography of Small Choroidal Melanoma Compared With
Choroidal Nevus

Variable
Tumor thickness, mm
Mean
Median (range)

Small Choroidal Melanoma

(n = 37)

Choroidal Nevus a
(n = 51)

1025
1019 (639-1410)

685
628 (184-1643)

NA

27 (73)
10 (27)

30 (59)
18 (35)

.48

0
37 (100)

3 (6)
48 (94)

.13

36 (97)
1 (3)
4 (11)

51 (100)
0
23 (45)

.24

1 (3)
35 (95)
1 (3)
0

18 (35)
22 (43)
4 (8)
2 (4)

NA

P Value

Choroid Features
Optical shadowing
Partial
Complete
Overlying choriocapillaris
Normal
Thinning

Bruch Membrane and Retinal Pigment Epithelium Features

Bruch membrane
Normal
Rupture
Drusen
Retinal pigment epithelium
Normal
Atrophy
Nodular
Absent

Retina Features
Outer
Photoreceptors
Normal
Absent
Shaggy
Inner segmentouter segment junction
Normal
Irregular
Absent
External limiting membrane
Normal
Irregular
Absent
Outer nuclear layer
Normal
Irregular
Absent
Outer plexiform layer
Normal
Irregular
Absent
Inner
Inner nuclear layer
Normal
Abnormal
Inner plexiform layer
Normal
Abnormal
Ganglion cell layer
Normal
Abnormal
Nerve fiber layer
Normal
Abnormal
Subretinal fluid
Subretinal lipofuscin deposition
Intraretinal edema

10 (27)
9 (24)
18 (49)

29 (57)
22 (43)
0

.005

12 (32)
1 (3)
24 (65)

29 (57)
19 (37)
3 (6)

.02

20 (54)
1 (3)
16 (43)

41 (80)
9 (18)
1 (2)

.008

30 (81)
1 (3)
6 (16)

47 (92)
4 (8)
0

.59

31 (84)
2 (5)
4 (11)

47 (92)
4 (8)
0

.12

34 (92)
3 (8)

48 (94)
3 (6)

.68

34 (92)
3 (8)

51 (100)
0

.04

34 (92)
3 (8)

51 (100)
0

.04

35 (95)
2 (5)
34 (92)
35 (95)
6 (16)

51 (100)
0
8 (16)
23 (45)
0

.001 b

.09
NA
NA
.003

Abbreviation: NA, not applicable because these are established risk factors that select small choroidal melanoma from choroidal nevus and were excluded from
the statistical analysis.
a Data are from the study by Shah et al.16
b Comparing absent vs shaggy photoreceptors by 2 test. All other P values are by t test and 2 test.

ARCH OPHTHALMOL / VOL 130 (NO. 7), JULY 2012

853

WWW.ARCHOPHTHALMOL.COM

2012 American Medical Association. All rights reserved.

Downloaded From: http://jamanetwork.net/ on 01/08/2014

Figure 2. Enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) of small choroidal melanoma compared with choroidal nevus. A
through D, Comparison of juxtapapillary small choroidal melanoma vs choroidal nevus. The EDI-OCT shows shaggy photoreceptors, shallow subretinal fluid, and
subretinal deposits (orange pigment) (A) overlying small choroidal melanoma (B) compared with choroidal nevus (C and D), with no subretinal fluid or with
moderate retinal pigment epithelial (RPE) alterations. E through H, Temporal macular small choroidal melanoma vs choroidal nevus. The EDI-OCT shows
subretinal fluid and shaggy photoreceptors (E) over small choroidal melanoma (F) vs choroidal nevus (G), with overlying minor RPE alterations (H). I through L,
Macular small choroidal melanoma vs choroidal nevus. The EDI-OCT shows shaggy photoreceptors and subretinal fluid (I) overlying small choroidal melanoma
( J) vs choroidal nevus (K), with choriocapillaris compression, no subretinal fluid, and intact retina (L). M through P, Amelanotic small choroidal melanoma vs
amelanotic choroidal nevus. The EDI-OCT shows shallow subretinal fluid (M) and subretinal deposits (orange pigment) overlying small choroidal melanoma (N)
compared with choroidal nevus (O), with lack of subretinal fluid, chronic retinal thinning with photoreceptor atrophy, and small RPE detachment (P).

found that choroidal thickness varied by age, with a decrement of 15.6 m per decade of life. Fujiwara and coworkers17 found that choroidal thickness decreased by
12.7 m per decade of life and by 8.7 m per diopter of
myopia. Little information exists in the literature on EDIOCT of choroidal tumors.16,19
Early investigations of time-domain OCT features of choroidal tumors were generally focused on overlying retinal
features because choroidal imaging was poor. In 2005,
Shields and colleagues12 published their findings of timedomain OCT (Stratus OCT model 3000; Carl Zeiss Ophthalmic Systems) features of choroidal nevus in 120 consecutive patients. With that system, information on
choroidal and retinal morphologic structure was evaluated, but little detail was available on the features or thickness of the choroidal mass, with the authors noting that
specific features of the choroidal nevus were limited to
its anterior surface with minimal penetration into the
mass.12(p243) Similar studies by Muscat et al9 and by Espinoza and colleagues10 using later versions of OCT were
focused mostly on the related retinal features of choroidal
nevus and melanoma, with little comment on the internal
features or thickness of the choroidal mass. Muscat and
coworkers commented that it was impossible to have both
the base and the surface of the tumour on the same
scan9(p121) for thickness measurement. The recent improvements in spectral-domain OCT imaging quality and
the development of EDI-OCT have permitted improved
resolution of retinal and choroidal features and allowed
increased depth of visualization into the choroid and sclera.
Few studies16,19,20 have reported on the use of EDIOCT for choroidal tumors. Torres and coworkers19 evalu-

ated 23 various choroidal tumors using EDI-OCT and were

able to measure the base and thickness with this modality
in only 10 cases (43%). They estimated that smaller tumors (9-mm diameter and 1-mm thickness) were best
for measurement. Most important, choroidal tumors that
were too small for identification by ultrasonography were
identified, imaged, and measured by EDI-OCT.
The technique of EDI-OCT is unsuitable for all patients. Shah and associates16 evaluated 104 eyes with choroidal nevus imaged using EDI-OCT and found that approximately 50% of cases provided suboptimal images. The
suboptimal images were related to older patient age (60
years), female sex, extramacular location of the tumor (3
mm from the foveola and 4 mm from the optic disc),
and larger basal diameter of nevus (5 mm). They concluded that patient cooperation was important and that
EDI-OCT imaging was ideal only for smaller choroidal tumors (3 mm), particularly those located in the macula.
Caliper measurement of choroidal tumors on EDIOCT has consistently shown lesser thickness compared
with ultrasonography. Shah and coworkers16 found that
choroidal nevus was measured as approximately 54% less
thick on EDI-OCT (mean, 685 m) compared with ultrasonography (mean, 1500 m). Similarly, herein we detected a 55% disparity between the measurement of small
choroidal melanoma by EDI-OCT (mean, 1025 m) vs ultrasonography (mean, 2300 m).16 This discrepancy could
be due to unintentional inclusion of a flat overlying retina
with the anterior surface of the choroidal tumor measurement, as well as inadvertent inclusion of sclera in the often imprecise identification of the posterior tumor margin on ultrasonography. Axial resolution of EDI-OCT is

ARCH OPHTHALMOL / VOL 130 (NO. 7), JULY 2012

854

WWW.ARCHOPHTHALMOL.COM

2012 American Medical Association. All rights reserved.

Downloaded From: http://jamanetwork.net/ on 01/08/2014

approximately 3 to 4 m compared with 10 m for timedomain OCT21 and approximately 50 to 200 m for ultrasonography.22 With thin choroidal tumors, a small misjudgment in caliper placement on EDI-OCT could lead to
a 5- to 10-m error, while caliper misplacement on ultrasonography might lead to a 200- to 400-m error. As tumors increase in thickness, ultrasonography has a more
important role in measurement because current EDIOCT technology cannot accurately image thick choroidal
melanoma.
In the present study, we had the opportunity to compare the features of small choroidal melanoma vs similarsized choroidal nevus. We found EDI-OCT abnormalities
at all levels of the retina, RPE, Bruch membrane, and choroid. Compared with choroidal nevus, small choroidal melanoma more often showed increased tumor thickness, subretinal fluid, subretinal lipofuscin deposition, and RPE
atrophy. These clinical features were excluded from the statistical analysis because they are established selection criteria for melanoma. Using EDI-OCT, the statistical analysis revealed that small choroidal melanoma compared with
choroidal nevus more often showed shaggy photoreceptors (P .001), loss of external limiting membrane
(P=.008), loss of inner segmentouter segment junction
(P=.02), irregularity of inner plexiform layer (P=.04), intraretinal edema (P=.003), and irregularity of ganglion cell
layer (P=.04). The term shaggy photoreceptors describes the
irregular, elongated, and presumed swollen photoreceptors from fresh subretinal fluid; in this series, shaggy photoreceptors were found on EDI-OCT in 18 eyes (49%) with
small choroidal melanoma and in no eye with choroidal
nevus (Table 2). We believe that this important feature reflects an estimate of the duration of retinal detachment because with time, the photoreceptors become atrophic and
the outer retina becomes thinned; structural loss of photoreceptors was found in 9 eyes (24%) with small choroidal melanoma and in 22 eyes (43%) with choroidal nevus.
Shaggy or elongated photoreceptors have been found
with other conditions that produce subretinal fluid. Matsumoto and colleagues23 studied central serous chorioretinopathy and calculated that the outer segments of the
photoreceptors increase from a normal 30 m in attached foveolar retina to an elongated 50 m in detached
foveolar retina. They further speculated that the elongated photoreceptor outer segments contain autofluorescent fluorophores that accumulate in the subretinal space
and can settle into the fornix of the detachment, leading
to the slight hyperautofluorescence of fresh subretinal fluid.
Limitations to our study include the few patients with
small choroidal melanoma. A larger cohort could provide more robust information. In addition, tumor measurement and EDI-OCT analysis were subject to individual interpretation similar to ultrasonography thickness
measurement. Another drawback is the reality that not
all EDI-OCT images were of identical quality, which could
have affected interpretation. Last, the diagnosis of small
choroidal melanoma in these eyes was established by experienced ocular oncologists (C.L.S. and J.A.S.) based on
suspicious clinical features, evidence of growth, and needle
biopsy specimen evidence of related genetic mutations.
Diagnostic bias could be present in our assessment of small
choroidal melanoma vs choroidal nevus. The EDI-OCT

data are descriptive and do not necessarily predict the

ability to diagnose a small choroidal melanoma vs a choroidal nevus. Future studies could reduce bias with prospective interpretation of EDI-OCT findings masked to
diagnosis.
In conclusion, EDI-OCT is an exciting technology for
imaging small choroidal tumors, allowing visualization
of detail not previously seen with other imaging modalities. Small choroidal melanoma expands the choroid, compresses the choriocapillaris, and is associated with numerous changes in the overlying retina, including the
presence of subretinal fluid with suggestive shaggy photoreceptors and disruption of the inner segmentouter
segment junction. Compared with similar-sized choroidal nevus, small choroidal melanoma is thicker and more
often demonstrates subretinal fluid, subretinal lipofuscin deposition, and shagginess to the photoreceptor layer.
Submitted for Publication: December 29, 2011; final revision received March 23, 2012; accepted March 26, 2012.
Correspondence: Carol L. Shields, MD, Ocular Oncology Service, Wills Eye Institute, Thomas Jefferson University, 840 Walnut St, Ste 1440, Philadelphia, PA 19107
(carol.shields@shieldsoncology.com).
Author Contributions: Dr C. L. Shields had full access to
all the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
Funding/Support: This study was supported by the Eye
Tumor Research Foundation (Drs C. L. Shields and J. A.
Shields).
Role of the Sponsors: The Eye Tumor Research Foundation had no role in the design or conduct of the study; in
the collection, analysis, or interpretation of the data; or in
the preparation, review, or approval of the manuscript.
REFERENCES
1. Shields JA, Shields CL. Posterior uveal melanoma: clinical features. In: Shields
JA, Shields CL, eds. Intraocular Tumors: An Atlas and Textbook. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:59-116.
2. Shields CL, Furuta M, Thangappan A, et al. Metastasis of uveal melanoma millimeterby-millimeter in 8033 consecutive eyes. Arch Ophthalmol. 2009;127(8):989-998.
3. Diener-West M, Hawkins BS, Markowitz JA, Schachat AP. A review of mortality
from choroidal melanoma, II: A meta-analysis of 5-year mortality rates following enucleation, 1966 through 1988. Arch Ophthalmol. 1992;110(2):245-250.
4. Shields CL, Shields JA, Kiratli H, De Potter P, Cater JR. Risk factors for growth
and metastasis of small choroidal melanocytic lesions. Trans Am Ophthalmol
Soc. 1995;93:259-275, discussion 275-279.
5. Shields CL, Cater JC, Shields JA, Singh AD, Santos MCM, Carvalho C. Combination of clinical factors predictive of growth of small choroidal melanocytic tumors.
Arch Ophthalmol. 2000;118(3):360-364.
6. Shields CL, Furuta M, Berman EL, et al. Choroidal nevus transformation into melanoma: analysis of 2514 consecutive cases. Arch Ophthalmol. 2009;127(8):
981-987.
7. The Collaborative Ocular Melanoma Study Group. Factors predictive of growth
and treatment of small choroidal melanoma: COMS Report No. 5. Arch Ophthalmol.
1997;115(12):1537-1544.
8. Schaudig U, Hassenstein A, Bernd A, Walter A, Richard G. Limitations of imaging
choroidal tumors in vivo by optical coherence tomography. Graefes Arch Clin
Exp Ophthalmol. 1998;236(8):588-592.
9. Muscat S, Parks S, Kemp E, Keating D. Secondary retinal changes associated with
choroidal naevi and melanomas documented by optical coherence tomography.
Br J Ophthalmol. 2004;88(1):120-124.
10. Espinoza G, Rosenblatt B, Harbour JW. Optical coherence tomography in the evaluation of retinal changes associated with suspicious choroidal melanocytic tumors.
Am J Ophthalmol. 2004;137(1):90-95.

ARCH OPHTHALMOL / VOL 130 (NO. 7), JULY 2012

855

WWW.ARCHOPHTHALMOL.COM

2012 American Medical Association. All rights reserved.

Downloaded From: http://jamanetwork.net/ on 01/08/2014

11. Shields CL, Materin MA, Shields JA. Review of optical coherence tomography
for intraocular tumors. Curr Opin Ophthalmol. 2005;16(3):141-154.
12. Shields CL, Mashayekhi A, Materin MA, et al. Optical coherence tomography of
choroidal nevus in 120 patients. Retina. 2005;25(3):243-252.
13. Say EA, Shah SU, Ferenczy S, Shields CL. Optical coherence tomography of retinal
and choroidal tumors [published online July 18, 2011]. J Ophthalmol. 2011;2011:
385058. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3145171/?tool=pubmed. Accessed April 10, 2012.
14. Spaide RF, Koizumi H, Pozzoni MC. Enhanced depth imaging spectral-domain
optical coherence tomography [published correction appears in Am J Ophthalmol. 2009;148(2):325]. Am J Ophthalmol. 2008;146(4):496-500.
15. Margolis R, Spaide RF. A pilot study of enhanced depth imaging optical coherence tomography of the choroid in normal eyes. Am J Ophthalmol. 2009;147
(5):811-815.
16. Shah SU, Kaliki S, Shields CL, Ferenczy SR, Harmon SA, Shields JA. Enhanced
depth imaging optical coherence tomography of choroidal nevus in 104 cases
[published online January 30, 2012]. Ophthalmology.
17. Fujiwara T, Imamura Y, Margolis R, Slakter JS, Spaide RF. Enhanced depth imaging

18.

19.
20.

21.

22.
23.

optical coherence tomography of the choroid in highly myopic eyes. Am J Ophthalmol.

2009;148(3):445-450.
Imamura Y, Fujiwara T, Margolis R, Spaide RF. Enhanced depth imaging optical
coherence tomography of the choroid in central serous chorioretinopathy. Retina.
2009;29(10):1469-1473.
Torres VL, Brugnoni N, Kaiser PK, Singh AD. Optical coherence tomography enhanced
depth imaging of choroidal tumors. Am J Ophthalmol. 2011;151(4):586-593, e2.
Singh AD, Belfort RN, Sayanagi K, Kaiser PK. Fourier domain optical coherence
tomographic and auto-fluorescence findings in indeterminate choroidal melanocytic lesions. Br J Ophthalmol. 2010;94(4):474-478.
Kiernan DF, Mieler WF, Hariprasad SM. Spectral-domain optical coherence tomography: a comparison of modern high-resolution retinal imaging systems. Am
J Ophthalmol. 2010;149(1):18-31.
Bamber JC, Tristam M. Diagnostic ultrasound. In: Webb S, ed. The Physics of
Medical Imaging. Philadelphia, PA: Adam Hilger; 1988:319-388.
Matsumoto H, Kishi S, Sato T, Mukai R. Fundus autofluorescence of elongated photoreceptor outer segments in central serous chorioretinopathy. Am J Ophthalmol.
2011;151(4):617-623, e1.

Correction
Error in Figure. In the Clinical Sciences article titled
Outer Retinal Tubulation: A Novel Optical Coherence
Tomography Finding by Zweifel et al, published in the
December 2009 issue of the Archives (2009;127[12]:
1596-1602), an error occurred in Figure 3E on page 1599.
In that figure, the top portion of the schematic should
have been labeled (from top to bottom) ONL, ELM, and
IS/OS. In addition, the last 2 sentences of the figure legend should have read as follows: A schematic (E) demonstrates focal disruption of the photoreceptor layer, invagination of remaining cells, and establishment of lateral
contact by the outermost photoreceptors leading to complete tubule formation. ELM indicates external limiting
membrane; ONL outer nuclear layer.

ARCH OPHTHALMOL / VOL 130 (NO. 7), JULY 2012

856

WWW.ARCHOPHTHALMOL.COM

2012 American Medical Association. All rights reserved.

Downloaded From: http://jamanetwork.net/ on 01/08/2014