Clinical Applications of Optical Coherence Tomography and Optical Coherence Tomography Angiography in Uveal Melanoma: A Narrative Review

Abstract

Uveal melanoma is the most common primary intraocular malignancy in adults, most frequently arising from the choroid, followed by the ciliary body and iris. Its diagnosis and management require precise characterization of tumor morphology, localization, and associated complications to optimize visual and systemic outcomes. Recent advances in optical coherence tomography (OCT), anterior segment OCT (AS-OCT), and OCT angiography (OCTA) have expanded the ophthalmologist's ability to non-invasively visualize structural and vascular changes associated with this disease. In fact, enhanced depth imaging (EDI) and swept-source (SS) OCT can provide detailed views of deep ocular structures, enabling early detection of hallmark features such as subretinal fluid, retinal pigment epithelium disruption, and dome- or mushroom-shaped choroidal elevations; AS-OCT improves evaluation of lesions of the anterior segment, revealing iris architecture distortion and angle involvement; OCTA facilitates the visualization of abnormal tumor vasculature and detection of radiation-induced microvascular changes, including capillary dropout and foveal avascular zone enlargement. Moreover, these imaging modalities have demonstrated utility in differentiating uveal melanoma from pseudomelanomas, such as choroidal nevi, hemangiomas, and metastases. The present review aims at objectively assessing the use of OCT and OCTA in the diagnosis, treatment, and follow up of ocular melanoma, emphasizing their crucial role in identifying pathologic biomarkers of this potentially fatal ocular disease.

Keywords: anterior segment imaging; artificial intelligence; choroidal imaging; choroidal melanoma; iris melanoma; multimodal imaging; ocular oncology; optical coherence tomography; optical coherence tomography angiography; uveal melanoma.

Figure 1

Optical coherence tomography scan in which two important signs of choroidal melanoma can be detected: exudative retinal detachment with subretinal fluid (red arrow) and choroidal profile elevation with mass effect (yellow arrows).

Figure 2

Multimodal imaging of the anterior segment in a patient with a ciliary body melanoma previously treated with brachytherapy. (a) Optical coherence tomography scan where it is not possible to evaluate the lesion, but it is only possible to see a widespread shadowing of the analyzed area (red square) related to the device resolution which does not allow such assessment. Conversely, the use of ultrasound biomicroscopy in transversal (b) and longitudinal (c) scan permits a clear visualization of the lesion, also allowing its measurement and evaluation over time (blue squares).

Figure 3

Fundus autofluorescence scan in which can be detected the pigmented lesion as hypoautofluorescence region (red arrows), with surrounding exudative retinal detachment (yellow arrows), that is considered as a malignant sign.