Enlargement of the genital hiatus is associated with prolapse recurrence in patients undergoing sacrospinous ligament fixation.

OBJECTIVE: To correlate genital hiatus (GH) size with surgical failures in patients undergoing sacrospinous ligament fixation (SSLF) and compare anatomic outcomes after classification based on GH size. METHODS: A retrospective review of 81 patients who underwent SSLF for apical prolapse from 2010 to 2016 at a teaching hospital. Anatomical outcome is reported using the Pelvic Organ Prolapse Quantifications System. A comparison of parametric continuous variables was performed using unpaired Student t test. Categorical variables were evaluated using Pearson's χ2 test and Fisher's exact test. A P value <0.05 was considered significant. RESULTS: Among the 81 patients, no difference in age, parity, body mass index, preoperative prolapse stage or follow-up time was noted between those whose surgery succeeded and those with failed surgery. Postoperatively, a widened GH was significantly associated with recurrent prolapse (P < 0.001). When the preoperative size of the GH was dichotomized into widened (≥4 cm) or normal (<4 cm), there was a non-significant (P = 0.444) trend of more failures in the widened GH group. A posterior colporrhaphy did not improve success. CONCLUSION: Both preoperative and postoperative widened GH correlated with having more surgical failures following SSLF. Importantly, postoperatively a normal size GH was significantly associated with more surgical success.

Uterus-Sparing Surgery: Outcomes of Transvaginal Uterosacral Ligament Hysteropexy.

STUDY OBJECTIVE: Recently, there has been a paradigm shift toward uterine conservation during the surgical management of pelvic organ prolapse (POP), specifically uterine prolapse. There are few reports on transvaginal uterosacral ligament hysteropexy (TULH). This study aimed to describe our surgical technique and outcomes. DESIGN: Retrospective review and description of surgical technique. Anatomic outcome has been reported using the POP quantification system. Complications were segregated. A comparison of parametric continuous variables was performed using paired t test. Categoric variables were evaluated using the Pearson χ2 test and the Fisher exact test. A p-value <.05 was considered significant. SETTING: Teaching hospital. PATIENTS: Forty patients who underwent TULH from 2009 to 2017. INTERVENTIONS: TULH. MEASUREMENTS AND MAIN RESULTS: A total of 40 patients met the inclusion criteria. Of these, 56.1% had preoperative stage 3 prolapse. The median operative time was 116 minutes. The mean estimated blood loss was 158.5 mL. Transient ureteral obstruction occurred in 2 patients. The mean follow-up time was 17.2 months, and all patients had significant improvement of prolapse (p <.001). There was also an improvement in urinary incontinence and bladder storage symptoms (p <.001). None of the patients were reoperated on for recurrent POP. CONCLUSION: TULH is an effective uterus-preserving surgical alternative for the treatment of uterovaginal prolapse and provides good apical support. It is also associated with a low short-term recurrence and incidence of reoperation. TULH is a viable option for suitable patients with uterovaginal prolapse who desire uterine conservation.

RETINOCYTOMA WITH VITREOUS SEEDING: NEW INSIGHTS FROM ENHANCED DEPTH IMAGING OPTICAL COHERENCE TOMOGRAPHY AND HIGH-RESOLUTION POSTERIOR SEGMENT ULTRASONOGRAPHY.

PURPOSE: To report an atypical case of a patient with symptomatic retinocytoma associated with diffuse calcified vitreous seeds. METHODS: Retrospective chart review. RESULTS: A 46-year-old healthy woman presented with a history of floaters in the right eye for several months. She had been referred for abnormal findings in the retina and vitreous on routine examination. Visual acuity was 20/20. An incidental retinocytoma associated with extensive calcified vitreous seeding was observed. Enhanced depth optical coherence tomography showed an absence of normal retinal layers with numerous cystoid cavities throughout the lesion. High-resolution 20-MHz posterior B-scan ultrasonography demonstrated that the calcified vitreous seeds emanated from the peaked portion of the retinal tumor. CONCLUSION: Calcified vitreous seeding is a rare finding associated with retinocytomas. Enhanced depth imaging optical coherence tomography and high-resolution B-scan ultrasonography may be useful tools in the diagnosis of this uncommon retinal tumor.

An update of a former FIGO Working Group Report on Management of Posterior Compartment Prolapse.

BACKGROUND: The FIGO Working Group (FWG) in Pelvic Floor Medicine and Reconstructive Surgery (2012-2015) established a consensus among international opinion leaders in evaluating current evidence and providing practice recommendations. OBJECTIVES: To provide an update of the previous clinical opinion report on conservative and surgical treatment of posterior compartment prolapse. SEARCH STRATEGY: Search of evidence was performed using Pubmed, Embase, and Cochrane Library databases up to August 2018. SELECTION CRITERIA: Controlled trials on posterior colporrhaphy, site-specific defect, transanal, abdominal, laparoscopic, and mesh repair. DATA COLLECTION AND ANALYSIS: Collective consensus on surgical outcomes was based on a decision-making process during meetings and multiple group consultations. MAIN RESULTS: Basic evaluation and conservative treatment precede surgical management. Surgical techniques are performed by vaginal, transperineal, transanal, abdominal, or laparoscopic approach. The transvaginal surgical route without mesh appears superior to the transanal route. No conclusions can be drawn based on clinical studies or randomized controlled trials of posterior colporrhaphy and laparoscopic rectopexy. CONCLUSIONS: Management of rectocele should include patients' history, quality of life questionnaires, and, in case of complex anorectal symptoms, imaging and functional studies. Evidence on the best type of posterior vaginal wall repair is still scarce. Randomized controlled trials are needed to determine the best approach to achieve safe, effective, and long-term anatomical and functional outcomes.

Site Selective Antibody-Oligonucleotide Conjugation via Microbial Transglutaminase.

Nucleic Acid Therapeutics (NATs), including siRNAs and AntiSense Oligonucleotides (ASOs), have great potential to drug the undruggable genome. Targeting siRNAs and ASOs to specific cell types of interest has driven dramatic improvement in efficacy and reduction in toxicity. Indeed, conjugation of tris-GalNAc to siRNAs and ASOs has shown clinical efficacy in targeting diseases driven by liver hepatocytes. However, targeting non-hepatic diseases with oligonucleotide therapeutics has remained problematic for several reasons, including targeting specific cell types and endosomal escape. Monoclonal antibody (mAb) targeting of siRNAs and ASOs has the potential to deliver these drugs to a variety of specific cell and tissue types. However, most conjugation strategies rely on random chemical conjugation through lysine or cysteine residues resulting in conjugate heterogeneity and a distribution of Drug:Antibody Ratios (DAR). To produce homogeneous DAR-2 conjugates with two siRNAs per mAb, we developed a novel two-step conjugation procedure involving microbial transglutaminase (MTGase) tagging of the antibody C-terminus with an azide-functionalized linker peptide that can be subsequently conjugated to dibenzylcyclooctyne (DBCO) bearing oligonucleotides through azide-alkyne cycloaddition. Antibody-siRNA (and ASO) conjugates (ARCs) produced using this strategy are soluble, chemically defined targeted oligonucleotide therapeutics that have the potential to greatly increase the number of targetable cell types.

Multifocal Primary Uveal Melanoma: Clinical and Molecular Characteristics.

We report two patients who developed a second distinct choroidal melanoma in the same eye following successful regression of their first choroidal melanoma after iodine-125 plaque brachytherapy. Neither patient demonstrated ocular melanocytosis, local tumor recurrence, or vitreous seeding. One patient had the second tumor arising from a previously documented choroidal nevus, and after undergoing enucleation, there was no detectable connection between the tumors on histopathologic examination. Germline BAP1 mutation was absent in both cases. Multifocal primary uveal melanoma is a rare entity in which the second tumor may occur either de novo or from a malignant transformation of a choroidal nevus. Known risk factors include ocular melanocytosis or germline BAP1 mutation. Additional underlying mechanisms have yet to be elucidated.

Total vaginectomy and urethral lengthening at time of neourethral prelamination in transgender men.

INTRODUCTION AND HYPOTHESIS: For transgender men (TGM), gender-affirmation surgery (GAS) is often the final stage of their gender transition. GAS involves creating a neophallus, typically using tissue remote from the genital region, such as radial forearm free-flap phalloplasty. Essential to this process is vaginectomy. Complexity of vaginal fascial attachments, atrophy due to testosterone use, and need to preserve integrity of the vaginal epithelium for tissue rearrangement add to the intricacy of the procedure during GAS. We designed the technique presented here to minimize complications and contribute to overall success of the phalloplasty procedure. METHODS: After obtaining approval from the Institutional Review Board, our transgender (TG) database at the University of Miami Hospital was reviewed to identify cases with vaginectomy and urethral elongation performed at the time of radial forearm free-flap phalloplasty prelamination. Surgical technique for posterior vaginectomy and anterior vaginal wall-flap harvest with subsequent urethral lengthening is detailed. RESULTS: Six patients underwent total vaginectomy and urethral elongation at the time of radial forearm free-flap phalloplasty prelamination. Mean estimated blood loss (EBL) was 290 ± 199.4 ml for the vaginectomy and urethral elongation, and no one required transfusion. There were no intraoperative complications (cystotomy, ureteral obstruction, enterotomy, proctotomy, or neurological injury). One patient had a urologic complication (urethral stricture) in the neobulbar urethra. CONCLUSIONS: Total vaginectomy and urethral lengthening procedures at the time of GAS are relatively safe procedures, and using the described technique provides excellent tissue for urethral prelamination and a low complication rate in both the short and long term.

Avascular Retinal Findings in a Child With Achondroplasia.

The authors present clinical and angiographic findings in a 12-year-old girl with achondroplasia who presented with bilateral retinal peripheral nonperfusion and unilateral rhegmatogenous retinal detachment, which has not been previously described in achondroplasia. This report contributes incremental knowledge regarding aberrant retinal vascular phenomena observed in pediatric disease states and implicates the possible role of mutations in the FGFR3 gene in peripheral vascular abnormalities. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:272-274.].

Evaluation and surgery for stress urinary incontinence: A FIGO working group report.

AIMS: To review available evidence regarding evaluation and treatment of stress urinary incontinence (SUI) and provide recommendations for management of urinary incontinence under specific conditions determined by the International Federation of Gynecology and Obstetrics (FIGO) Working Group. METHODS: The FIGO Working Group discussed the management of SUI during meetings and assessed the evidence. The search of evidence was performed using MEDLINE® and Cochrane databases as well as additional searches from societies and major organizations for additional guidelines and recommendations and hand searches from bibliographies. Initial searches from 1985 to December 31, 2012 extended until July 15, 2015. After review, recommendations are made based on levels of evidence according to the recommendations from Oxford EBM Center. RESULTS: Initial evaluation of SUI consists of history and physical examination; cough stress test, evaluation for urinary tract infections (UTI), assessment of urethral mobility, and post-void residual volumes (LOE 5). Urodynamic studies are not necessary to evaluate patients with uncomplicated SUI (LOE 1a). Conservative treatment should be tried prior to surgery and more importantly in areas of low resources (LOE 5). Midurethral slings (MUS), pubovaginal (traditional suburethral) slings (PVS), and Burch colposuspension are effective in treating SUI (LOE 1a). Patients with SUI with ISD or UUI appear to have lower cure rates than patients without (LOE 2-4). There are limited data on surgical outcomes under limited resources (LOE 5). CONCLUSIONS: MUS, PVS, and Burch colposuspension are effective treatments for SUI. Evidence for recommendations to treat patients in underserved low resource areas is lacking. Neurourol. Urodynam. 36:518-528, 2017. © 2016 Wiley Periodicals, Inc.

MACULAR HOLE AFTER PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To report the clinical features, possible associations and treatment outcomes of patients with macular hole after pars plana vitrectomy (PPV) (single or multiple) for rhegmatogenous retinal detachment (RD). METHODS: Retrospective consecutive case series from July 2009 to July 2014. RESULTS: In the 15 study patients, the average time from RD surgery to macular hole diagnosis was 119 days (range: 41-398 months). Possible associations include epiretinal membrane (73%, 11/15 patients), macula-off RD (60%, 9/15 patients), recurrent RD (47%, 7/15 patients), and high myopia (56%, 5/9 patients). Single surgery was successful in hole closure in 8/15 patients (Group A) while 7/15 patients underwent multiple surgeries (Group B). Macular hole closure was achieved in 7/8 (87.5%) patients in Group A compared to 4/7 (57.1%) patients in Group B. Improvement of at least two lines of Snellen's visual acuity was achieved in 4/8 (50.0%) and 4/7 (57.1%) patients in Group A and B, respectively. CONCLUSION: In patients with macular hole formation after pars plana vitrectomy for RD, possible associations were epiretinal membrane, macula-off RD, recurrent RD, and high myopia. Even when macular hole closure was achieved, limited visual improvement occurred.

Endophthalmitis Associated With Glaucoma Drainage Implants.

BACKGROUND AND OBJECTIVE: To identify the clinical features, organisms, and treatment outcomes in patients with endophthalmitis associated with glaucoma drainage implants. PATIENTS AND METHODS: A retrospective noncomparative case series. RESULTS: Of the 13 patients, exposure occurred in eight eyes, including exposure of the tube in four eyes, exposure of the patch graft in three eyes, and exposure of the plate in one eye. In the remaining five eyes, either recent implant placement or conjunctival revision occurred. The most common organism was Staphylococcus epidermidis (five eyes). Intravitreal antibiotics were administered in all eyes, with the exception of one eye (primary evisceration). Removal of the implant was performed in six eyes and evisceration or enucleation was performed in three eyes. Median pre-infection visual acuity was 20/80 (range: 20/30 to hand motion). Visual acuity at last follow-up was no light perception (five eyes), light perception (two eyes), hand motion (one eye), and better than or equal to 20/200 (five eyes). CONCLUSION: Clinical features associated with endophthalmitis include implant exposure and a history of recent surgery. Staphylococcus epidermidis was the most common isolate. Although removal of the implant was performed in many patients, successful treatment was accomplished in some patients without removal. Visual outcomes were generally poor. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:563-569.].

Retinal Detachment After Subretinal Stem Cell Transplantation.

A 60-year-old man with Stargardt's macular dystrophy and visual acuity of 20/400 in the right eye and 20/60 in the left eye underwent a subretinal injection of autologous bone marrow-derived stem cells in the right eye. The patient developed a retinal detachment in the right eye 2 months later that was initially treated with a scleral buckle, but the patient subsequently developed a recurrent retinal detachment with proliferative vitreoretinopathy. A pars plana vitrectomy, membrane peel, fluid-air exchange, endolaser, and silicone oil injection were then performed. The retina remained attached 5 months later, with improvement in visual acuity from hand motions to 20/300 post-vitrectomy. Retinal detachment may occur after subretinal injection of stem cells. Proliferative vitreoretinopathy may develop in these patients, but the visual acuity may return to baseline after retinal reattachment. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:600-601.].

Prelamination of Neourethra with Uterine Mucosa in Radial Forearm Osteocutaneous Free Flap Phalloplasty in the Female-to-Male Transgender Patient.

Radial forearm free flap phalloplasty is the most commonly performed flap for neophallus construction in the female-to-male (FtM) transgender patient. Urological complications, however, can arise quite frequently and can prevent the patient from urinating in the standing position, an important postsurgical goal for many. Using mucosa to construct the fixed urethra and to prelaminate the penile urethra has been successful in reducing urologic complications, particularly strictures and fistulas. Until now, only buccal, vaginal, colonic, and bladder sites have been described as sources for these mucosal grafts. We present the successful use of uterine mucosa for prelamination of the neourethra in an FtM patient who underwent hysterectomy and vaginectomy at the prelamination stage of a radial forearm phalloplasty. Three months postoperatively, the patient was able to void while standing and showed no evidence of stricture or fistula on retrograde cystogram. These results suggest that uterine mucosa may be used for prelamination of the penile neourethra in patients undergoing phalloplasty.

Uveal melanoma: An analysis of cellular features and comparison to monosomy 3 status.

BACKGROUND: Choroidal and ciliary body melanomas divide into two approximately equal groups. Local therapy cures one group while the other metastasizes and proves lethal. Monosomy 3 strongly associates with aggressive behavior. We analyzed a series of choroidal and ciliary body melanomas to describe the cellular features and to compare them to monosomy 3 status using the latter as a surrogate for survival. METHODS: One hundred eleven specimens met the study's inclusion criteria. Following ThinPrep processing, samples were analyzed for cellular features including: cell type, nuclear grade, tumor infiltrating lymphocytes, and the presence of necrosis and melanin. FISH analysis for monosomy 3 was performed on ThinPrep slides using a threshold of 20% monosomic cells per 200 melanoma cells. RESULTS: Seventy-two tumors (65%) had a mixed cell type while spindle cell type and epithelioid cell type occurred in 37 (33%) and 2 (1.8%), respectively. Seventy-five tumors (68%) had Grade 2 nuclear atypia. Monosomy 3 occurred in 57 tumors (51%). Significantly more tumors with Grade 3 nuclei had monosomy 3 (79% vs.43%, P = 0.002) and metastases (29% vs. 8%, P = 0.01). None of the 11 pure spindle cell tumors with Grade 1 nuclei metastasized or had monosomy 3. CONCLUSIONS: Uveal melanoma has a relatively consistent cellular appearance, characterized by a mixed cell pattern and no more than moderate nuclear atypia. This consistent appearance aids in the cellular diagnosis but limits prognostication using cellular features. Cellular features significantly associate with monosomy 3 status only in the minority of tumors at the extremes of the morphologic spectrum.

Fine-needle aspiration biopsy of uveal melanoma: outcomes and complications.

PURPOSE: To report outcomes and complications of fine-needle aspiration biopsy (FNAB) of uveal melanoma performed for diagnostic and prognostic purposes. METHODS: Prospective interventional case series of 150 consecutive patients with a clinical diagnosis of uveal melanoma. The FNAB approach (transcorneal (TCO), transscleral (TSC) and transvitreal (TVT) was primarily determined by the location of the tumour. The FNAB was performed using a 25-gauge needle using a previously published technique. Prognostication was done using fluorescent in situ hybridisation detection of monosomy of chromosome 3. RESULTS: FNAB was obtained via TCO (8), TSC (71) and TVT (64) approach and impression smear in seven cases. Diagnostic yield was 92%. False-negative results were observed in 8%. Diagnostic yield was significantly correlated to biopsy approach (TCO 100%, TSC 96%, TSV 86%; p=0.029) and tumour size (basal diameter >5.0 mm; height >2.5 mm). Persistent haemorrhage (subretinal haemorrhage or vitreous) requiring surgical intervention (1%) and rhegmatogenous retinal detachment (1%) were rare. Endophthalmitis, hypotony, tumour recurrence, episcleral seeding were not observed over the average follow-up of 37 months. Prognostication could be performed in 85% of cases. Overall, only 47% of eligible patients enrolled into the adjuvant therapy trial. CONCLUSIONS: FNAB for uveal melanoma with 25-gauge needle is a safe procedure that can yield diagnostic and prognostic information in vast majority of cases (92% and 85%, respectively). Even so, only about half of the eligible cases eventually enrolled into the adjuvant therapy trial. Possibility of negative FNAB yield should be considered when counselling patients with small tumours. Alternative means of diagnostic biopsy and methods of prognostication need to be assessed for small tumours.

CHOROIDAL MELANOMA INITIALLY TREATED AS HEMANGIOMA: DIAGNOSTIC AND THERAPEUTIC CONSIDERATIONS.

PURPOSE: To describe and analyze cases of circumscribed choroidal melanoma initially treated as circumscribed choroidal hemangioma. METHODS: A retrospective case series including five eyes of five patients with choroidal melanoma that were originally diagnosed and treated as choroidal hemangioma. RESULTS: Four men and 1 woman (26-61 years) were included. All patients were white and presented with nonspecific symptoms (visual field defect, decreased visual acuity, and metamorphopsia) and visual acuity ranging from 20/30 to 20/80. Four of the five tumors were yellow and/or orange and one was partially melanotic. All tumors were dome shaped (one bilobed) and had associated subretinal fluid overlying the lesion. Two tumors had high internal reflectivity on standardized A-scan ultrasonography, whereas others had low internal reflectivity. Three tumors were hypofluorescent on early phases of indocyanine green and intrinsic vasculature was also observed in two of these three. Four of five patients who were initially treated by photodynamic therapy did not respond to treatment. However, they did respond to radiation therapy (after revised diagnosis), with documented regression and no evidence of detectable metastasis (mean follow-up 24.2 months). CONCLUSION: Differentiating between amelanotic melanoma and choroidal hemangioma can be challenging. Relying solely on ophthalmoscopic features can be misleading. Ancillary studies such as indocyanine green and standardized A-scan ultrasonography bring clarity in differentiating circumscribed choroidal hemangioma from choroidal melanoma. Although cytology or histopathology is the only definitive method of establishing the diagnosis, careful emphasis on key diagnostic features can obviate the need for diagnostic fine-needle aspiration biopsy in most cases.

Diagnostic Fine-Needle Aspiration Biopsy for Iris Melanoma.

PURPOSE: The aim of this study was to describe a case of iris melanoma diagnosed by fine-needle aspiration biopsy (FNAB) with review of the literature. DESIGN: This study presents a case report and review of the literature. METHODS: A 76-year-old white man presented with iris melanoma arising from preexisting iris nevus that was confirmed cytologically by a transcorneal FNAB. RESULTS: A pigmented lesion on the left iris extending from 3 to 8:30 o'clock, from the iris root to the pupillary margin without ectropion uveae, was biopsied through 1-mm clear corneal incision. A short 25-gauge needle was inserted into the tumor while applying aspiration, and 10-0 suture was used to close the wound. Cytopathology confirmed the presence of spindle-shaped cells with conspicuous cytoplasmic melanin and nuclear atypia consistent with the diagnosis of melanoma. There were no intraoperative or postoperative complications. The patient was subsequently treated with radiation plaque brachytherapy. CONCLUSIONS: Although indicated only in minority of cases, it is important to consider FNAB for the diagnosis and management of iris lesions.

Diagnostic Cytologic Features of Uveal Melanoma.

PURPOSE: To report the cytologic characteristics of uveal melanoma. DESIGN: This is a prospective, single-center study of consecutive patients. SUBJECTS: All patients with a clinical diagnosis of uveal melanoma from May 2009 to July 2013 who underwent prognostication fine-needle aspiration biopsy (FNAB) were included. METHODS: The cytologic characteristics of uveal melanoma were analyzed for 150 consecutive patients with a clinical diagnosis of uveal melanoma who were treated at the Cleveland Clinic Cole Eye Institute between May 2009 and August 2012. MAIN OUTCOME MEASURES: Cellular features of all cases were analyzed for cell type, presence of melanin, nuclear grade, tumor-infiltrating lymphocytes, and necrosis. Cytology was then correlated with histopathology in enucleated eyes. RESULTS: A total of 150 patients were included. Seven samples of tumor resections were excluded from the study because they were studied by impression smears. A total of 143 FNAB samples of 143 patients formed the basis for analysis. Fifty-three percent of the patients were male, and the average age for all patients was 60 years. Transcorneal (n = 8), transscleral (n = 71), and transvitreal (n = 64) approaches were used. Of 143 samples, 131 were adequate. Among these, spindle cells were observed in 98% (63% mixed and 35% spindle only), whereas only epithelioid cells were observed in 2 samples. Melanin granules were observed in 80% of samples. Tumor nuclear grade (atypia) increased with tumor height and by tumor location (least atypia with iris tumors). CONCLUSIONS: Cytologic features such as spindle cells and melanin granules, present in 98% and 80% of samples, respectively, are important cytologic diagnostic features. Tumor nuclear grade (atypia) increased with tumor height. Iris melanoma has bland features compared with ciliary and choroidal melanoma.

De novo Evolution of a Small Choroidal Melanoma.

AIM: To report the evolution of a de novo choroidal melanoma. METHOD: This is a case report of a 22-year-old white male patient who has been undergoing periodic examination for a choroidal 'freckle' since 10 years of age. RESULTS: In 2007, a fundus photograph of the left eye showed a nondescript area of choroidal hyperpigmentation temporal to the fovea. Progressive growth was observed and, by 2012, the lesion had become well circumscribed and raised. One year later, a 4.5 × 4.5 × 1.5 mm, dome-shaped, pigmented, choroidal mass with subretinal fluid and orange pigmentation was evident. The lesion was classified as a small choroidal melanoma. Six months after plaque radiotherapy, tumor regression with total resolution of the subretinal fluid was documented. CONCLUSION: The distinction between small choroidal melanoma and choroidal nevus is not absolute; therefore, some choroidal melanomas may initially be mislabeled as choroidal nevi because of their small size until continued growth identifies them to be small choroidal melanomas. In our case, the documented growth of the choroidal lesion on each consecutive visit and its high-risk features strongly suggest that it had been a melanoma from the beginning. To our knowledge, this is only the second documented case of a de novo evolution of a small choroidal melanoma.