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In the article by Pollack et al1on "Ocular Complications in Ehlers-Danlos Syndrome Type IV," the authors noted ocular complications from an attempted repair on a carotid-cavernous sinus fistula. Their conclusion stated that the diagnosis of Ehlers-Danlos syndrome type IV should be "considered in any young or middle-aged patient seen with spontaneous direct CCF [carotid-cavernous sinus fistula]." We have recently seen a patient with Ehlers-Danlos syndrome type IV and suggest that subretinal hemorrhage should be considered as a diagnosis in these patients when a mass in the choroid simulating a melanoma is detected. We examined a 45-year-old man with Ehlers-Danlos syndrome type IV who had a subconjunctival hemorrhage and an intraocular mass at the region of the equator (Figure 1). The mass itself measured 7.5×8.0 mm, was 3.9 mm high, and exhibited medium to high reflectivity on ultrasonography (Figure 2) A fluorescein angiogram was not obtained because of the Ehlers-Danlos

A large, pigmented episcleral mass is likely to be a malignant melanoma. We treated a patient with a "pseudomelanoma" that was secondary to localized silver deposition. Report of a Case. —An 85-year-old man presented for a routine ophthalmic examination. His pertinent history included strabismus surgery of the left eye 67 years earlier. The most significant finding was a large conjunctival and episcleral pigmented mass localized over the insertion of the left lateral rectus muscle, with a symblepharon to the left lateral canthus (Fig 1). The patient was uncertain of the lesion's duration. The mass was grayish black, showed minimal intrinsic vascularity, and did not move freely with the conjunctiva. No corresponding intraocular pigmentation was present, the conjunctiva was otherwise clear, and the remainder of the ophthalmic and general physical examination findings were unremarkable. A history of eyedropuse was indeterminate. The diagnosis was a benign pigmented episcleral lesion, related to

Both free-floating and fixed pigmented cysts occur in the anterior chamber. 1-8 Although an occasional fixed or implanted pigmented cyst may simulate a malignant melanoma, 8 the innocuous nature of these cysts is generally determinable on routine clinical examination. The present report concerns an eye that was enucleated because one of these cysts lodged in the anterior chamber was mistaken for a malignant melanoma. Report of Case Clinical History. —During the course of a routine examination of a 50-year-old white woman, an ophthalmologist discovered a pigmented spot in the anterior chamber angle of the patient's left eye at 4 o'clock. The remainder of his examination of both eyes revealed nothing abnormal. Two months later when the pigmented lesion had increased slightly in size, the patient was referred to another ophthalmologist. Complete ophthalmologic examination, including the use of the gonioscope and slit lamp, revealed a small, dark mass, 1.5 mm in

• Histological markers enable the correct diagnosis of a pigmented lesion that histologically resembles a superficial spreading malignant melanoma and yet behaves in a wholly benign way. This pseudomelanoma occurs in young adults within a few weeks following partial surgical-shave excision of an intradermal melanocytic nevus. (Arch Dermatol111:1588-1590, 1975)

• A 20-year-old white woman had extensive surgery for "metastatic melanoma" of the dorsum of the right foot and surgical removal of two regional inguinal lymph nodes. Review of the histopathological sections ten years later revealed all three lesions to be cellular blue nevi. Cellular blue nevi may resemble melanoma histologically and, relative to their incidence, are quite frequently found in lymph nodes. Thus they may present a uniquely challenging differential diagnosis with metastatic melanoma. ( Arch Dermatol 1984;120:367-370)

Nevus sebaceus of Jadassohn is an organoid nevus composed of varying admixtures of sebaceous glands, hair follicles, and apocrine glands. The degree of differentiation of these appendages can be related to age. Clinically this nevus appears as a yellow, hairless plaque on the scalp or face of infants, but it may occasionally arise in adult life or in unusual locations such as the back or the inguinal or pubic regions. Cerebriform, linear, irregular, zosteriform, and multiple lesions have all been described. 1,2 Development of various malignant or benign adnexal tumors often occurs with advancing age but can be seen in young adults. 3 Recently, Fellner and Katz 4 emphasized the occasional close clinical resemblance of pigmented basal cell carcinoma to superficial spreading melanoma. The following case of pseudomelanoma arising in a patient with nevus sebaceus is another example of the diagnostic dilemma these lesions can cause. Report of a Case

This paper reports a very unusual case of a melanocytoma (nevus) of the ciliary body with involvement of the overlying sclera which masqueraded as a malignant melanoma. Report of Patient A 62-year-old white man noted that a dark growth was present on his left sclera at the 4:30 o'clock meridian for about five months. The patient did not observe any change in size of the lesion, nor did it give him any symptoms. There was no history of injury to the area. About one month prior to admission, two ophthalmologists examined the patient. Both made a diagnosis of malignant melanoma of the ciliary body and advised enucleation. The patient was referred for still another opinion. His visual acuity was 6/7.5 in the right eye and 6/6 in the left with correction. The tension was 15 mm Hg Schiotz in each eye. Two darkly pigmented lesions were seen on the sclera