Table 1.

Imaging features of pigmented fundus lesions

Lesion	Imaging Modalities
	Clinical Appearance	FAF	OCT	US	FA/ICG	OCTA
Benign
FANNUM	Pigmented Discrete Flat	IsoAF	Hyperreflective or nearly imperceptible Sometimes shadowing	Flat	Non-contributory	Normal overlying vasculature
RPE hyperplasia	Deeply pigmented Discrete Associated with trauma or inflammation	HypoAF	Optically dense Posterior shadowing	Acoustically solid High internal reflectivity	Hypofluorescent early, hyperfluorescent zones late	Can show vascular flow signals on outer retinal slab
CHRPE Solitary  Multifocal (bear tracks)	Deeply pigmented Well demarcated Round Flat or minimally elevated Depigmented lacunae Depigmented halo Unilateral Clustered Sector distribution Smaller than solitary No lacunae or halo	HypoAF Lacunae can be hyperAF	Overlying retinal thinning, photoreceptor loss RPE thick, irregular RPE loss in lacunae Moderate shadowing Subretinal cleft Choroidal atrophy	≤1 mm thick	Blocked choroidal fluorescence Window defect in lacunae No leakage	Normal retinal and choroidal vasculature
RPE hamartoma associated with FAP and Gardner (pigmented ocular fundus lesions)	Gray Irregular depigmented margins Fish-tail, comma, or comet configuration Flat, minimally elevated Multifocal, randomly distributed (not sector) Bilateral Associated with FAP and Gardner Syndrome	HypoAF	Outer retinal attenuation RPE thick	Too thin to resolve	Blocked choroidal fluorescence Window defect in depigmented areas Associated telangiectatic dilations hyperfluorescent	Reduced vascular density in superficial capillary plexus Increased vascular density in deep capillary plexus
Congenital simple hamartoma of the RPE	Deeply pigmented Discrete Solitary nodule, protrudes through sensory retina Central macula, usually adjacent to foveola Minimally dilated feeding artery and draining vein Mild retinal traction Sometimes exudation Sometimes pigmented vitreous cell	HypoAF	Hyperreflective Abruptly elevated Solid mass in inner retina Dome-shaped Elevation into vitreous Complete optical shadowing	Too thin to resolve	Hypofluorescent	Vascular networks at the superficial and deep plexus
Combined hamartoma of the retina and RPE	Gray Ill-defined Tortuous or straightened retinal vessels Retinal dragging Peripheral retinal ischemia, neovascularization Unilateral, if bilateral consider NF2	HypoAF	Vitreoretinal traction Retinal striae Sawtooth or folded pattern replacing full thickness retina Epiretinal membrane	Acoustically solid mass	Late staining on FA Patchy hypercyanescence on ICG	Disorganized intralesional retinal microcirculation
Suspect
Nevus	Pigmented or partially pigmented Less often amelanotic Well-demarcated Overlying drusen Overlying RPE changes Sometimes depigmented halo Less often CNV Risk factors for growth to melanoma: Visual acuity loss to 20/50 or worse Diameter >5mm	HypoAF Halo slightly hyper AF Orange hyperAF Orange pigment	Thick, elevated choroid Overlying SRF Overlying retinal edema PEDs, drusen Fibrous metaplasia SRF	Solid or hollow Usually <2mm thick Thickness >2mm Acoustic hollowness	Variable on FA Hypocyanescent	Hyporeflective Intense vascular rim called surface microvasculature Avascular areas Intact RPE-Bruch’s complex Possible CNV
Melanocytosis	Gray to brown Diffuse or sector Usually unilateral Concomitant iris, episcleral, cutaneous involvement Congenital 1/400 risk of uveal melanoma	IsoAF	Choroid thick	Used to help detect melanoma	Utilized if concern for melanoma	Normal overlying vasculature
Melanocytoma	Dark brown to black Feathery margin Usually unilateral Commonly involves optic disc Can have choroidal and retinal component Sometimes vitreous seeds	HypoAF	Optically dense Dome-shaped Abrupt shadowing	Dome Medium to high internal reflectivity	Hypofluorescent	Intact overlying retinal vasculature Irregular intratumoral vascular network
Malignant
Melanoma	Pigmented or partially pigmented Less often amelanotic Well-demarcated Less often diffuse Serous retinal detachment Shifting subretinal fluid Orange pigment Blocks transillumination	Orange hyperAF	Thick, elevated choroid Subretinal fluid Shaggy photoreceptors Thin or compressed choriocapillaris	Dome or mushroom Acoustically hollow Low internal reflectivity	Mottled hyperfluorescene in filling phases Diffuse late staining Pinpoint leaks (hot spots) Double circulation sign Hypocyanescent	Iso- to hyporeflective Avascular areas Vascular loops Vascular networks Loss of choriocapillaris flow Obscured RPE-Bruch’s complex Obscured outer retinal layer Dilated and tortuous feeding vessels
RPE adenoma / adenocarcinoma	Deeply pigmented Feeder arterioles Exudation Arising from CHRPE	Not well described	High reflectivity Dense posterior shadowing	Abruptly elevated, “derby hat” Acoustically solid High internal reflectivity	Hypofluorescent early, hyperfluorescent zones late	Minimal flow (single case report)

Abbreviations: FAF = fundus autofluorescence, OCT = optical coherence tomography, US = ultrasound, FA/ICG = fluorescein angiography/indocyanine green angiography, OCTA = optical coherence tomography angiography, FANNUM = focal aggregates of normal or near normal uveal melanocytes, IsoAF = isoautofluorescent, RPE = retinal pigment epithelium, HypoAF = hypoautofluorescent, CHRPE = congenital hypertrophy of the retinal pigment epithelium HyperAF = hyperautofluorescent, FAP = familial adenomatous polyposis, NF2 = neurofibromatosis type 2, SRF = subretinal fluid, PED = pigment epithelial detachment CNV = choroidal neovascularization