Blurred vision as the sole initial presentation of disseminated lung malignancy

Abstract

Symptomatic choroidal metastasis (CM) is a rare presenting feature of disseminated lung malignancy. Detection of the primary malignancy usually precedes ocular findings. We report a rare case of blurred vision secondary to bilateral CM as the sole initial manifestation of disseminated lung malignancy in a female patient. Pulmonary symptoms appeared 2 months later. She received radiotherapy and palliative chemotherapy and survived for 7 months after the initial presentation.

Introduction

Choroidal metastasis is rare in disseminated extraocular malignancy whereas it is common with intraocular malignant tumors. Leading cause of CM is reported to be carcinoma of the lung in males and carcinoma of the breast in females. However, clinical reports of female patients presenting with ocular symptoms as the initial manifestation of lung carcinoma are rare.

Case report

A 56 year old woman presented with blurred vision in the Left eye for 3 weeks. There were no other systemic complaints and there was no history of any associated systemic diseases.

Her best corrected snellens visual acuity was 6/36 in the right eye and 2/60 in the left. Anterior segment examination was within normal limits in both eyes. Fundoscopy in right eye revealed a moderately elevated subretinal mass temporally in the midperipheral retina. Left eye showed a moderately elevated subretinal mass inferiorly associated with exudative retinal detachment involving the macula. (Fig. 1A and B) Fundus Fluorescein Angiography (Fig. 1C and D) and A-B Scan ultrasound (Fig. 2) supported a clinical suspicion of bilateral choroidal metastasis. She was evaluated by physicians and an oncology team to find out the site of primary malignancy.

Figure 1.

Colour fundus photographs of the right (A) and left eye (B) showing subretinal mass in both eyes with associated serous retinal detachment in left eye. Fluoresceine angiography of right (C) and left (D) eyes showing diffuse hyperfluorescence of the tumor (blue arrow) and white arrows showing the extent of retinal detachment.

Figure 2.

A-B Scan Ultrasound showing a dome shaped mass with variable reflectivity.

CT of Chest showed a heterogeneous contrast enhancing lesion with a hypodense area in the left lower lobe associated with pleural effusion and multiple rounded pulmonary nodules scattered in both lungs (Fig. 3E). CT of abdomen showed renal and liver metastasis.

Figure 3.

CT-Scan of chest (E) showing mass lesion in the left lower lobe of lung (white arrow) and multiple pulmonary nodules. PET/CT scan of abdomen (F) showing hepatic metastasis.

CT Scan of head showed metastatic deposits in the right frontal bone and meninges. Fine needle aspiration biopsy from left lung showed atypical cells suspicious of malignancy, which could not be characterized further. PET/CT Scan was highly suggestive of disseminated malignancy involving the liver (Fig. 3F), skull, meninges and bones (Fig. 4).

Figure 4.

PET/CT Scan showing metastasis in the skull (G) and bones(H).

Two months after the initial presentation she developed cough with hemoptysis and weight loss. She was commenced on radiotherapy followed by chemotherapy for palliation. She survived for 7 months after the initial presentation.

Discussion

Metastasis is the most common intraocular malignancy with choroid being the most preferred site of interest owing to its abundant vascular supply from the posterior ciliary arteries.^1–3 Perls reported the first case of choroid metastasis in 1872.³

Incidence of CM from metastatic lung disease was reported to be 2–6.7% in clinical trials.³ However clinical reports of patients presenting with symptomatic CM as the initial manifestation of lung malignancy are rare.^2,4,6,7 Prevalence of symptomatic CM is reported to be 1–3%.⁷ Breast and lungs are the frequent primary sites followed by GIT, ovary and thyroid.³

Whole body 18-Fluoro 2-deoxyglucose PET/CT scan is widely used now for screening, staging and management of patients with cancer.²

CM can result in a marked decrease in vision usually <6/60. It is very sensitive to radiotherapy and chemotherapy. Aggressive treatment will decrease the metastasis size, but most of the patients will not show much improvement in vision.^5,7 Treatment options for CM depend on both systemic and ocular status.² Life expectancy of patients with CM in general is about 6–9 months.⁸ Palliative treatment should be offered to avoid further deterioration of vision and to maintain the quality of life during the remaining life span of the patient.⁹

Though CM is described as a rare entity, with increase in the cancer rates and cancer survival, it will become a major cause of visual impairement.^7,10 Acute visual loss in a healthy patient as the first sign of an unknown primary tumor can easily be overlooked by ophthalmologists as well as by the patient. This report is a reminder that malignancy can present atypically and could be of assistance to clinicians who encounter a similar rare scenario.

Conflict of interest

The authors declared that there is no conflict of interest.