Sir,

Hyphema associated with an iris naevus suggests malignant transformation.1, 2 Here, we report a case of iris naevus with recurrent spontaneous hyphema simulating an iris melanoma.

Case report

A 58-year-old female patient presented with blurred vision in the right eye because of a recurrent hyphema. Visual acuity was 20/60, and intraocular pressure was 14 mmHg. Five days later the hyphema cleared, and vision improved to 20/30. Slit-lamp examination revealed a brown coloured tumour at the 12 o’clock position, located in the middle portion of the iris touching the cornea. There was hyphema originating from the lesion (Figure 1a). Ultrasound biomicroscopy showed a 3.47 × 2.02 × 2.22 mm-sized solid iris mass without involvement of the ciliary body or the anterior chamber angle (Figure 1b). Fundus examination was unremarkable. A week later, the patient visited our clinic with decreased visual acuity (20/400) and a recurrent hyphema from the iris tumour. Orbital MRI showed an enhancing lesion at the level of the iris in the corresponding meridian. Oncologic evaluation disclosed no abnormalities suggesting a metastatic source. We suspected an iris melanoma with secondary bleeding. Tumour removal by transcorneal excisional sector iridectomy and iridoplasty with a modified McCannel suture technique using 10-0 polypropylene (Prolene) were performed. Histopathologic examination of the iris revealed scattered cells having round bland-looking nuclei and abundant heavily pigmented cytoplasm consistent with the diagnosis of a melanocytic naevus (Figure 1c). The patient regained 20/30 visual acuity, and at 6 months post-operatively had not developed additional complications.

Figure 1
figure 1

(a) Slit-lamp photograph at initial presentation showing a brown pigmented iris mass with corneal touching and haemorrhage hanging down. (b) Ultrasound biomicroscopy of solid iris tumour showing low internal echogenicity. (c) Histopathologic examination of the excised iris tumour with blood clot (hematoxylin-eosin stain, 12.5 × magnification). Inset (hematoxylin-eosin stain, 100 × magnification) shows scattered cells with round bland-looking nuclei and abundant heavily pigmented cytoplasm consistent with the melanocytic naevus.

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Comment

It is estimated that 4–5% of suspicious iris naevi transformed into malignant melanomas.3 Clinical parameters most predictive of malignant potential on melanocytic iris tumours include larger tumour size, secondary glaucoma, pigment dispersion, prominent intralesional vasculature, tumour-related symptoms, and documented enlargement of the lesion.4 Photocoagulation may be an option to control recurrent hyphema in a benign naevus.5 In our case, largest basal tumour diameter greater than 3 mm, presence of pigment dispersion, and tumour-related symptoms gave rise to the possibility of an iris melanoma. Our patient demonstrated that iris naevus can present with recurrent spontaneous hyphema.