Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Choroidal metastases

Choroidal metastases are the most common malignant intraocular lesion, found in 4-12% of necropsy series of patients with solid cancer [S2]. They arise mostly from breast and lung cancer and can be the first sign of an undiagnosed malignancy [S8] [S12]. Treatment is usually palliative, aiming to preserve vision and quality of life [S4] [S10].

Key points - The choroid accounts for 90% of uveal metastases; breast (37%) and lung (27%) are the commonest primaries [S8]. - A yellow mass with subretinal fluid, echodense on ultrasonography and "lumpy bumpy" on OCT, suggests the diagnosis [S8]. - External beam radiotherapy is the standard treatment, with complete response in about 80% [S2]; a short course of 20 Gy in 5 fractions also preserved vision in 80% of eyes [S4]. - Systemic targeted therapy or immunotherapy can shrink metastases, but ocular relapse usually needs radiotherapy [S5]. - Prognosis is poor: 32% survival at 3 years and 24% at 5 years in 1111 patients [S8].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• No known cancer. Choroidal metastasis can precede diagnosis of the primary tumour [S12]; in 16% of cases the primary site remains unknown [S8].
• Lung cancer presenting through the eye. In 55 patients whose lung cancer first presented as choroidal metastasis, most were male smokers and adenocarcinoma was the commonest type [S1].
• Bilateral or multifocal lesions. These are most often from breast cancer [S3].
• Blind painful eye. Enucleation is an option [S3].

Recognise it

• Decreased vision was the presenting symptom in 61% of eyes in one radiotherapy series [S4].
• Typical features: mean 1.7 metastases per eye, mean base 11.6 mm and thickness 3.2 mm, yellow colour in 86% and subretinal fluid in 72% [S8].
• Unilateral, unifocal metastases are more common with lung cancer [S3].

Confirm it

• Ultrasonography: echodense mass in 80% [S8].
• OCT: "lumpy bumpy" choroidal surface in 64% [S8]. Fluorescein and indocyanine green angiography complement fundoscopy [S5].
• Biopsy: fine needle aspiration biopsy is occasionally used when the primary is unknown [S8]; choroidal biopsy can confirm the metastatic nature and help identify the primary [S5].
• Systemic workup with the oncology team; in lung cancer presentations, bronchoscopic lung biopsy was the commonest diagnostic route [S1].

Manage it

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Tier A (primary care / no specialist)

• A person with known cancer and new blurred vision needs an eye examination (see Refer when) [S4] [S12].

Tier B (general eye clinic)

• Suspect metastasis in a yellow choroidal mass with subretinal fluid, especially with a cancer history [S8].
• Use ultrasonography where available to confirm an echodense mass [S8].
• Coordinate with the oncology team: treatment depends on systemic status and the number, location and laterality of tumours [S3].
• Observation is an option for patients with poor systemic status or with asymptomatic or resolved disease [S3].

Tier C (specialist centre)

1. External beam radiotherapy. Standard regimens of 30 Gy in 10 fractions or 40 Gy in 20 fractions, as reported in [S2], gave complete response in about 80% and improved acuity in 57% to 89% [S2]. A hypofractionated course of 20 Gy in 5 fractions, as reported in [S4], gave tumour regression in 91% of 71 eyes with few toxicities [S4]. Short-course radiotherapy for orbital and ocular metastases improved vision in 11 of 13 patients [S6]. In a small Japanese series and literature review, vision improved or stabilised in 80% of patients [S11].
2. Systemic therapy. Chemotherapy, immunotherapy, hormone therapy or whole eye radiotherapy are options for active, multifocal and bilateral disease [S3]. Systemic therapy may suit pauci-symptomatic metastases in widespread disease, while radiotherapy remains necessary for symptomatic lesions [S2]. Secondary resistance is common, so local treatment alongside or after systemic therapy may give more durable control [S10].
3. Focal therapy for solitary lesions. Plaque radiotherapy, transpupillary thermotherapy or photodynamic therapy suit active solitary metastases [S3]. Brachytherapy and proton therapy may be proposed for isolated metastases with long disease-free intervals [S2].
4. Photodynamic therapy. In a meta-analysis of 52 tumours, thickness fell in 82% and subretinal fluid resolved in 75% of eyes, with no adverse events reported [S9].
5. Gamma knife radiosurgery. A meta-analysis mostly of uveal melanoma (34 metastases) reported local control in 96% [S7].
6. Office-based palliation. Photodynamic therapy and intravitreal anti-VEGF injections may preserve vision while reducing time in hospital [S5].

Refer when

Pitfalls

• Missing a first presentation of cancer: metastasis can precede the primary diagnosis [S1] [S12].
• Assuming systemic therapy alone gives durable ocular control [S5] [S10].
• Offering long radiotherapy courses when short courses work for palliation [S4] [S6].
• Confusing metastasis with amelanotic melanoma: imaging features help separate them [S8].

Evidence notes

• There are no prospective trials of treatment; the literature is mainly retrospective, with few reports of late toxicity [S2].
• PDT outcomes come from pooled case reports, so selection bias is likely [S9].
• Not covered by these sources: anti-VEGF dosing, specific targeted agents by tumour type, and evidence-based referral timings.

Related articles

• Choroidal naevus versus small melanoma
• Uveal melanoma: diagnosis and primary treatment

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.