Clinical science
Autofluorescence of choroidal melanoma in 51 cases
Ocular Oncology Service, Wills
Eye Institute, Thomas Jefferson
University, Philadelphia, PA, USA
Correspondence to:
Dr C L Shields, Ocular Oncology
Service, Suite 1440, Wills Eye
Institute, 840 Walnut Street,
Philadelphia, PA 19107, USA;
carol.shields@shieldsoncology.
com
CLS has had full access to all
the data in the study and takes
responsibility for the integrity of
the data and the accuracy of the
data analysis.
Accepted 11 January 2008
Br J Ophthalmol 2008;92:617–622. doi:10.1136/bjo.2007.130286
C L Shields, C Bianciotto, C Pirondini, M A Materin, S A Harmon, J A Shields
ABSTRACT
Aim: To describe the autofluorescence features of
choroidal melanoma.
Design: Non-comparative case series.
Participants: 51 consecutive patients.
Methods: Standard fundus photography and autofluor-
escence photography (580 nm excitation, 695 nm barrier
filter) were performed on all patients. Clinical features
were correlated with autofluorescence features.
Main outcome measure: Autofluorescence features of
choroidal melanoma and overlying retinal pigment
epithelium (RPE).
Results: The mean patient age was 59 years. The
choroidal melanoma was a mean of 3.6 mm from the
optic disc and 2.6 mm from the foveola. The mean
tumour basal dimension was 11 mm and the mean
tumour thickness was 4 mm. The choroidal melanoma
showed intrinsic hypoautofluorescence (39%), isoauto-
fluorescence (6%) and hyperautofluorescence (55%).
Slightly increased hyperautofluorescence of the mela-
noma was found in pigmented tumours (versus non-
pigmented), those with greater thickness and basal
dimensions, and those with overlying disrupted RPE.
Related RPE hyperplasia and atrophy showed hypoauto-
fluorescence, drusen, RPE detachment and subretinal fluid
showed slight hyperautofluorescence, and orange pig-
ment displayed the brightest hyperautofluorescence.
Conclusions: Choroidal melanoma generally shows slight
intrinsic hyperautofluorescence and the brightness
increases with pigmented tumours, larger tumours, and
those associated with disrupted RPE. Overlying orange
pigment shows remarkably bright hyperautofluorescence.
Autofluorescence of cutaneous melanoma has been
under investigation for nearly two decades.1–11 The
focus has been on digital autofluorescence imaging
for early detection of cutaneous malignancy.
Chwirot and coworkers9 screened 7228 pigmented
cutaneous lesions with low-intensity ultraviolet A
autofluorescence (366 nm) and found a sensitivity
of 83% and specificity of 60% for the detection of
melanoma. They commented that this tool could
be used for screening large populations to identify
patients with possible cutaneous melanoma.
Farina and coworkers8 evaluated autofluores-
cence of 237 pigmented cutaneous lesions with a
telespectrophotometric technique using selected
wavelengths between 420 and 1040 nm. They
found that light in the infrared region (940 nm)
was most useful in the discrimination of malignant
from benign tumours, whereas light in the visible
yellow range (578 nm) was most beneficial for
evaluation of the lesion dimension.8 Most authors
believe that cutaneous autofluorescence results for
pigmented cutaneous lesions should not be inter-
preted alone, but used in conjunction with physical
examination, clinical risk factors and dermoscopy
when making a judgement on malignant poten-
tial.6 7 9
There is little information on the role of
autofluorescence for intraocular tumours.12–18 In
this report, we evaluate the autofluorescence
features of choroidal melanoma and related retinal
and retinal pigment epithelial (RPE) changes.
METHODS
The clinical records, fundus photographs and
optical coherence tomography (OCT) and fundus
autofluorescence images of 51 consecutive patients
with choroidal melanoma were reviewed. The
fundus autofluorescence was performed with
standard filters2 (580 nm excitation, 695 nm bar-
rier filter) to avoid imaging the autofluorescence of
the lens, using a Zeiss camera (Carl Zeiss Meditec
Inc, Jena, Germany) and Ophthalmic Imaging
Systems (OIS) (Sacramento, California, USA) soft-
ware. The autofluorescence features of choroidal
melanoma were evaluated on the basis of the
appearance of the choroidal tumour relative to
surrounding normal choroid. Related autofluores-
cence features of the retina and RPE were also
studied. The features were graded according to
autofluorescence (hypoautofluorescent, isoauto-
fluorescent or hyperautofluorescent relative to
the surrounding normal choroid/RPE), degree of
autofluorescence (trace (1+), moderate (2+), or
marked (3+)) and granular pattern of autofluores-
cence (non-granular, fine granular, coarse granu-
lar). These features were then correlated with the
clinical features.
RESULTS
Fifty-one patients (mean age 59 years (median 59,
range 24–89); 27 (53%) men; 50 (98%) caucasian
and one (2%) Hispanic) with choroidal melanoma
were imaged with fundus photography and auto-
fluorescence. Visual acuity was 20/20 to 20/40 in
28 (55%) eyes, 20/50 to 20/100 in 21 (41%), and
20/200 or worse in two (4%).
Table 1 lists the clinical fundus features of the
tumours. The mean tumour basal dimension was
11 mm and mean thickness was 4 mm. The
melanomas displayed intrinsic hypoautofluorescence
(39%), isoautofluorescence (6%) and hyperautofluor-
escence (55%) (fig 1). Pigmented melanomas showed
hyperautofluorescence in 60%, whereas non-pig-
mented tumours showed hyperautofluorescence in
43% (tables 2 and 3). Thicker melanomas (.3 mm)
exhibited hyperautofluorescence in 59%, whereas
thinner tumours ((3 mm) showed hyperautofluor-
escence in 50%. Melanoma with greater basal
dimension (.11 mm) showed hyperautofluores-
cence in 63%, whereas smaller tumours ((11 mm)
showed hyperautofluorescence in 50%. Tumours in
the macula and macula to equator showed relatively
617
 Clinical science

Table 1 Clinical features of 51 consecutive eyes with Table 3 General summary of autofluorescence of choroidal melanoma
choroidal melanoma in 51 consecutive eyes relative to tumour pigmentation, location and size
Clinical feature Autofluorescence

Location quadrant Hypo Iso Hyper

Macula 18 (35) Choroidal melanoma (n = 51) +
Inferior 10 (20) Melanoma pigmentation
Temporal 10 (20) Pigmented (n = 37) +
Superior 12 (24) Non-pigmented (n = 14) +
Nasal 1 (2) Melanoma anteroposterior location
Location anteroposterior Macula (n = 18) +
Macula 18 (35) Macula to equator (n = 30) +
Macula to equator 30 (59) Equator to ora (n = 3) +
Equator to ora serrata 3 (6) Melanoma quadrant location
Distance (mm) to: Macula (n = 18) +
Optic disc 3 (4, 0–15) Inferior (n = 10) +
Foveola 2 (3, 0–12) Temporal (n = 10) +
Tumour size (mm) Superior (n = 12) ++
Base 11 (11, 4–26) Nasal (n = 1) +
Thickness 3 (4, 0–11) Melanoma thickness
Melanoma colour (3 mm (n = 24) +
Brown 37 (73) .3 mm (n = 27) +
Yellow 14 (27) Melanoma basal dimension
Values are either number (%) or median (mean, range). (11 mm (n = 32) +
.11 mm (n = 19) +
Other melanoma features
similar autofluorescence. The autofluorescence quality of the Bruch’s membrane rupture (n = 5) +
melanoma was granular in 92% of cases and non-granular in 8% Retinal invasion (n = 4) +
(table 4).
3+, marked; 2+, moderate; 1+, trace.
Both RPE hyperplasia and atrophy exhibited general hypoauto-
fluorescence. In contrast, RPE detachment and orange pigment the RPE was disrupted due to hyperplasia, atrophy, detachment,
showed hyperautofluorescence (tables 5 and 6 and fig 2). Drusen fibrous metaplasia or orange pigment, the overall intrinsic
and subretinal fluid displayed mild hyperautofluorescence, and autofluorescence of underlying melanoma was more visible and
orange pigment showed the brightest hyperautofluorescence. If slightly more intense (tables 7 and 8).

Table 2 Autofluorescence of choroidal melanoma in 51 consecutive eyes relative to tumour pigmentation,

location and size
Autofluorescence
Hypo Hyper
Clinical feature 3+ 2+ 1+ Iso 1+ 2+ 3+

Melanoma (n = 51) 1 (2) 7 (14) 12 (24) 3 (6) 14 (27) 9 (18) 5 (10)

Melanoma pigmentation
Pigmented (n = 37) 1 (3) 5 (14) 6 (16) 3 (8) 10 (27) 7 (19) 5 (14)
Non-pigmented (n = 14) 0 (0) 2 (14) 6 (43) 0 (0) 4 (29) 2 (14) 0 (0)
Melanoma anteroposterior location
Macula (n = 18) 0 (0) 2 (11) 7 (39) 0 (0) 4 (22) 5 (28) 0 (0)
Macula to equator (n = 30) 1 (3) 4 (13) 4 (13) 3 (10) 10 (33) 4 (13) 4 (13)
Equator to ora (n = 3) 0 (0) 1 (33) 1 (33) 0 (0) 0 (0) 0 (0) 1 (33)
Melanoma quadrant location
Macula (n = 18) 0 (0) 2 (11) 7 (39) 0 (0) 4 (22) 5 (28) 0 (0)
Inferior (n = 10) 1 (10) 2 (20) 2 (20) 1 (10) 3 (30) 0 (0) 1 (10)
Temporal (n = 10) 0 (0) 2 (20) 0 (0) 2 (20) 4 (40) 2 (20) 0 (0)
Superior (n = 12) 0 (0) 1 (8) 1 (8) 0 (0) 3 (25) 3 (25) 4 (33)
Nasal (n = 1) 0 (0) 0 (0) 1 (100) 0 (0) 0 (0) 0 (0) 0 (0)
Melanoma thickness
(3 mm (n = 24) 0 (0) 3 (13) 8 (33) 1 (4) 6 (25) 4 (17) 2 (8)
.3 mm (n = 27) 1 (4) 4 (15) 4 (15) 2 (7) 8 (30) 5 (19) 3 (11)
Melanoma basal dimension
(11 mm (n = 32) 1 (3) 2 (6) 10 (31) 3 (9) 7 (22) 5 (16) 4 (13)
.11 mm (n = 19) 0 (0) 5 (26) 2 (11) 0 (0) 7 (37) 4 (21) 1 (5)
Other melanoma features
Bruch’s membrane rupture (n = 5) 2 (40) 0 (0) 0 (0) 2 (40) 1 (20) 0 (0) 0 (0)
Retinal invasion (n = 4) 1 (25) 1 (25) 0 (0) 2 (50) 0 (0) 0 (0) 0 (0)
Values are number (%).
3+, marked; 2+, moderate; 1+, trace.

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 Clinical science

Table 4 Granularity of autofluorescence of choroidal melanoma in 51 Table 6 General summary of autofluorescence of choroidal melanoma
consecutive eyes relative to tumour pigmentation in 51 consecutive eyes relative to retinal and retinal pigment epithelial
Autofluorescence granularity (RPE) features
Granular Granular Autofluorescence
Tumour pigmentation Non-granular fine coarse Hypo Iso Hyper
Choroidal melanoma overall (n = 51) 4 (8) 7 (14) 40 (78) RPE hyperplasia (n = 6) +
Choroidal melanoma pigmented 2 (5) 3 (8) 32 (86) RPE detachment (n = 1) ++
(n = 37) RPE fibrous metaplasia (n = 3) +
Choroidal melanoma non-pigmented 2 (14) 4 (29) 8 (57) RPE atrophy (n = 8) ++
(n = 14)
Orange pigment (n = 39) ++
Values are number (%). Drusen (n = 9) +
Subretinal fluid (n = 46) +
Cystoid macular oedema (n = 12) +
3+, marked; 2+, moderate; 1+, trace.

Table 5 Autofluorescence of choroidal melanoma in 51 consecutive eyes relative to retinal and retinal pigment epithelial (RPE) features
Autofluorescence
Hypo Hyper
Feature
Clinical feature 3+ 2+ 1+ Iso 1+ 2+ 3+ not present

RPE hyperplasia (n = 6) 1 (17) 1 (17) 2 (33) 1 (17) 0 (0) 1 (17) 0 (0) 45

RPE detachment 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (100) 0 (0) 50
(n = 1)
RPE fibrous metaplasia 1 (33) 0 (0) 0 (0) 1 (33) 1 (33) 0 (0) 0 (0) 48
(n = 3)
RPE atrophy (n = 8) 2 (25) 1 (13) 2 (25) 1 (13) 1 (13) 1 (13) 0 (0) 43
Orange pigment 0 (0) 0 (0) 0 (0) 0 (0) 11 (28) 19 (49) 9 (23) 12
(n = 39)
Drusen (n = 9) 0 (0) 0 (0) 0 (0) 3 (33) 5 (56) 1 (11) 0 (0) 42
Subretinal fluid 0 (0) 0 (0) 4 (9) 13 (28) 22 (48) 5 (11) 2 (4) 5
(n = 46)
Cystoid macular 0 (0) 0 (0) 0 (0) 4 (33) 8 (66) 0 (0) 0 (0) 39
oedema (n = 12)
Values are number (%).
3+, marked; 2+, moderate; 1+, trace.

Table 7 Autofluorescence of choroidal melanoma in 51 consecutive eyes relative to status of overlying retinal pigment epithelium (RPE)
Autofluorescence
Hypo Hyper
Clinical feature 3+ 2+ 1+ Iso 1+ 2+ 3+

Melanoma overall
(n = 51)
Overlying RPE 1 (11) 1 (11) 3 (33) 1 (11) 1 (11) 1 (11) 1 (11)
intact (n = 9)
Overlying RPE not 0 (0) 6 (14) 9 (21) 2 (5) 13 (31) 8 (19) 4 (10)
intact* (n = 42)
Pigmented melanoma
(n = 37)
Overlying RPE 1 (25) 0 (0) 0 (0) 1 (25) 0 (0) 1 (25) 1 (25)
intact (n = 4)
Overlying RPE not 0 (0) 5 (15) 6 (18) 2 (6) 10 (30) 6 (18) 4 (12)
intact* (n = 33)
Non-pigmented
melanoma (n = 14)
Overlying RPE 0 (0) 1 (20) 3 (60) 0 (0) 1 (20) 0 (0) 0 (0)
intact (n = 5)
Overlying RPE not 0 (0) 1 (11) 3 (33) 0 (0) 3 (33) 2 (22) 0 (0)
intact* (n = 9)
Values are number (%).
*RPE not intact includes RPE hyperplasia, detachment, fibrous metaplasia, atrophy and orange pigment.
3+, marked; 2+, moderate; 1+, trace.

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 Clinical science

Table 8 General summary of autofluorescence of choroidal melanoma In the 46 patients with active subretinal fluid, the fluid rim
in 51 consecutive eyes relative to status of overlying retinal pigment appeared with slightly more hyperautofluorescence than the
epithelium (RPE) fluid centre. In the five patients with a break in the Bruch’s
Autofluorescence membrane, the edge of the rupture showed slightly brighter
Clinical feature Hypo Iso Hyper
autofluorescence than the centre.

Melanoma overall (n = 51)

Overlying RPE intact (n = 9)
Overlying RPE not intact* (n = 42)
Pigmented melanoma (n = 37)
Overlying RPE intact (n = 4)
Overlying RPE not intact* (n = 33)
Non-pigmented melanoma (n = 14)
Overlying RPE intact (n = 5)
Overlying RPE not intact* (n = 9)
3+, marked; 2+, moderate; 1+, trace.
* RPE not intact includes RPE hyperplasia, detachment, fibrous metaplasia, atrophy
and orange pigment.
+ DISCUSSION
+ Fundus autofluorescence is a relatively new, non-invasive tool for
imaging the posterior segment of the eye. Its usefulness as a
+ diagnostic tool for age-related macular degeneration, retinal
++ dystrophies and inflammatory retinal conditions is unfolding.19–
24
Few reports have been published on the role of autofluorescence
+ for investigating intraocular tumours. In 1995, Lohmann and
+ coworkers12 recognised that uveal melanoma in vitro had few
autofluorescent properties, but the overlying RPE showed brilliant
endogenous fluorescence. They speculated that even though the
fluorescence emitted from the tumour was low, this diagnostic

Figure 1 Autofluorescence of choroidal

melanoma. (A) Pigmented choroidal
melanoma with intrinsic
isoautofluorescence (B) and with
overlying ring-like hyperautofluorescence
of orange pigment, central
hypoautofluorescence of reduced
lipofuscin, and trough of mildly
hyperautofluorescent subretinal fluid. (C)
Optical coherence tomography (OCT)
confirms subretinal fluid. (D) Pigmented
choroidal melanoma with trace intrinsic
hyperautofluorescence (E) seen best on
the anterior margin. Note the overlying
bright hyperautofluorescent orange
pigment, central hypoautofluorescent
lipofuscin reduction and trough of
hyperautofluorescent subretinal fluid. (F)
OCT reveals submacular fluid. (G)
Pigmented choroidal melanoma with
trace intrinsic hypoautofluorescence (H)
seen best on the superotemporal margin
where retinal pigment epithelium (RPE) is
intact. Note the overlying bright
hyperautofluorescent orange pigment,
central hypoautofluorescence of
lipofuscin reduction and shallow trough of
hyperautofluorescent subretinal fluid on
the superonasal margin. (I) OCT reveals
shallow subfoveal fluid. (J) Non-
pigmented choroidal melanoma appears
hypoautofluorescent (K), particularly at
the Bruch’s membrane rupture. Note the
overlying bright hyperautofluorescence of
‘‘brown’’ orange pigment and central
hypoautofluorescence from lipofuscin
reduction. (L) OCT reveals shallow
subretinal fluid overlying the abruptly
elevated mass.

620 Br J Ophthalmol 2008;92:617–622. doi:10.1136/bjo.2007.130286

 Clinical science

Figure 2 Autofluorescence of retinal

pigment epithelial (RPE) alterations
related to choroidal melanoma. (A) Subtle
orange pigment overlying pigmented
choroidal melanoma shows bright
hyperautofluorescence (B), absent central
lipofuscin appears hypoautofluorescent,
and subtle subretinal fluid into the macula
displays slight hyperautofluorescence. (C)
Optical coherence tomography (OCT)
reveals shallow subretinal fluid overlying
the elevated choroidal mass. (D) Subtle
orange pigment overlying submacular
choroidal melanoma shows bright
hyperautofluorescence (E) and absent
central lipofuscin appears
hypoautofluorescent. (F) Shallow
subretinal fluid, found on OCT appears
slightly hyperautofluorescent (E). (G)
Choroidal melanoma with overlying
fibrous metaplasia of the RPE shows
hypoautofluorescence (H), and subtle
subretinal fluid appears
hyperautofluorescent. (I) The OCT
documents the elevated mass and slight
retinal thinning and disorganisation
overlying the mass. (J) Tiny, new-onset,
submacular choroidal melanoma with
brightly hyperautofluorescent (K) orange
pigment and moderately
hyperautofluorescent subretinal fluid,
confirmed on OCT (L).

tool might be useful for evaluation and differentiation of uveal
melanoma and nevus. Very little was published on this subject
until 2007 when Lavinsky and associates13 commented on five
eyes with choroidal melanoma in vivo, in which the autofluor-
escence findings were mostly related to the RPE alterations, and
little information was provided on the tumour itself. Gunduz and
associates14 recognised a direct correlation of orange pigment and
hyperpigmentation with increased autofluorescence in 23 patients
with choroidal nevus or melanoma. Bakri and coworkers15 showed
autofluorescence emitted by lipofuscin in two eyes with choroidal
melanoma. Shields et al17 commented on the brilliant hyperauto-
fluorescence of orange pigment (lipofuscin) overlying small
choroidal melanoma, even when the lipofuscin was relatively
inconspicuous on colour photography.
In this analysis, we evaluated the autofluorescence of both
the melanoma and the related retinal/RPE alterations.
Autofluorescence features were correlated with the clinical
features. Indeed, melanoma had relatively mild autofluorescent
properties with the current standard technique of 580 nm
excitation and 695 nm barrier filter on a digital fundus camera.
We found that melanomas displayed hypoautofluorescence
(39%), isoautofluorescence, (6%) and hyperautofluorescence
(55%), and the hyperautofluorescence increased with larger
tumours, pigmented tumours and those with disrupted overlying
RPE. The autofluorescence property of melanoma was of a
granular quality in 92% of cases and non-granular in 8%. Fundus
autofluorescence of choroidal melanoma was studied by Lavinsky
and coworkers13 using scanning laser ophthalmoscopy with
slightly different wavelength parameters (488 nm excitation and
500 nm barrier filter), but there were no observable findings
within the tumour. Our results show perhaps more intrinsic
autofluorescence of choroidal lesions than those of Lavinsky et al,
as the excitation wavelength in our model was longer. Farina and
coworkers8 evaluated patients with pigmented cutaneous lesions

Br J Ophthalmol 2008;92:617–622. doi:10.1136/bjo.2007.130286 621

 Clinical science
using selected wavelengths between 420 and 1040 nm and found
that the ideal wavelength was 940 nm for discriminating
melanoma from nevus and 578 nm for discerning tumour
margins. Perhaps future studies on the role of fundus autofluor-
escence in investigating choroidal melanocytic lesions should
evaluate near-infrared wavelengths (780–820 nm), which pene-
trate deeper into the choroid than shorter wavelengths and can
excite melanin-associated fluorophores.23 25
Our group recently evaluated 64 eyes with choroidal nevus
using fundus autofluorescence.18 Overall, choroidal nevi showed
darker autofluorescence than melanoma, as nevi were hypoau-
tofluorescent in 56%, isoautofluorescent in 19% and hyperauto-
fluorescent in 25% of cases. Similar to melanoma, choroidal
nevus showed slightly brighter autofluorescence with increasing
size, increasing intrinsic pigmentation and disruption of over-
lying RPE. Despite these observations, the information obtained
with standard autofluorescence (580 nm excitation and 695 nm
barrier filter) was subtle. Similar to melanoma, the brightest
hyperautofluorescence was found with overlying orange pig-
ment, RPE detachment, subretinal fluid and drusen, in decreas-
ing order. With current settings, it is doubtful whether intrinsic
tumour autofluorescence can differentiate choroidal nevus from
melanoma, but information from the overlying RPE could be
important in the diagnostic differentiation, as bright hyper-
autofluorescence of orange pigment and subretinal fluid is more
often found with melanoma. In contrast, areas of dark RPE
hypoautofluorescence generally signify atrophy or hyperplasia,
features often associated with nevi.
The origin of autofluorescence in skin melanoma is not
completely understood. It is speculated that it results from
endogenous fluorophores, including collagen, elastin, desmosine
and keratin.1–3 5 Within the eye, several tissues are known to be
autofluorescent, including the cornea, lens, RPE, sclera and
melanocytes within the choroid.5
In summary, the current standard autofluorescent technique
(580 nm excitation, 695 nm barrier filter) provides subtle
information on intrinsic autofluorescence of choroidal mela-
noma and more obvious information on the related RPE/retinal
alterations. Future applications might focus on improved
imaging of the melanoma itself by using a multispectral
technique to identify optimal wavelengths, particularly in the
near-infrared range, for visualisation of the tumour and each of
its related findings. As further information is uncovered, the
potential benefits of autofluorescence photography in the early
detection of melanoma will be realised.
Funding: Support provided by the Retina Research Foundation of the Retina Society in
Cape Town, South Africa to CLS), the Paul Kayser International Award of Merit in
Retina Research, Houston, TX (to JAS), a donation from Michael, Bruce, and Ellen
Ratner, New York, NY (to JAS, CLS), Mellon Charitable Giving from the Martha W
Rogers Charitable Trust, Philadelphia, PA (to CLS), the LuEsther Mertz Retina Research
Foundation, New York, NY (to CLS), and the Eye Tumour Research Foundation,
Philadelphia, PA (to CLS, JAS). The sponsors did not participate in the design or
622
conduct of this study, in the collection, analysis or interpretation of the data, or in the
preparation, review or approval of the manuscript.
Competing interests: None declared.
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