Acute exudative paraneoplastic polymorphous vitelliform maculopathy as a first presentation of metastatic melanoma

Case 1An 80-year-old man, with a history of melanomas, presented to ophthalmology and reported newonset blurred vision in the last month.Ophthalmic history included stable glaucoma.Fundoscopy demonstrated multiple bilateral serous areas of retinal detachment with yellowish vitelliform lesions scattered across both maculae (Fig 1, A). Fundus autofluorescence, used to determine pathologic changes of the retina and retinal pigmented epithelium, showed multiple bilateral areas of dark gray hypofluorescence foci around the maculae (Fig 1, B). Optical coherence tomography showed gross edema below the maculae bilaterally with normal choroidal thickness (Fig 1, C ).The symptoms and investigative findings were consistent with acute exudative polymorphous vitelliform maculopathy.This is a rare immune-mediated maculopathy that can be idiopathic or paraneoplastic (acute exudative polymorphous vitelliform maculopathy).No choroidal melanoma was detected by ophthalmology.He was referred to dermatology for a skin check.Relevant medical history included 3 thin melanomas, benign prostate hyperplasia, and a transient ischemic attack.He previously attended dermatology for melanoma in situ (MIS) on his left scapula in 2013 and a clinical stage IA, Breslow thickness 0.45 mm, from his left cheek in 2015.He was subsequently discharged after clear surgical margins and appropriate follow-up.He was diagnosed with a third melanoma (MIS) on his mid back in 2023 (Fig 2).This was also managed surgically with clear margins.His brother also had a melanoma.The patient was referred to the cancer genetics service.He had no clinically concerning skin lesions on examination.A urology examination and prostatespecific antigen was normal.Computed tomography of the thorax, abdomen, and pelvis showed diffuse metastasis (of unknown primary) with lesions in the liver, retroperitoneum, and abdomen.He had a magnetic resonance imaging of the brain several weeks beforehand, for a transient ischemic attack, which showed no suspicious lesions.There had been no weight loss and he was otherwise well.Systemic blood tests, including lactate dehydrogenase, were normal.