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Primary malignancy requires regular ocular examinations
A patient presented for yearly fundus photos to follow a choroidal nevus.
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A 67-year-old Caucasian woman presented for her yearly dilated eye examination. Her ocular history included cryotherapy for treatment of a horseshoe tear and localized retinal detachment in the right eye in January 2011. She was being followed for a choroidal nevus in her right eye with yearly fundus photos. The patient stated that her visual acuity was stable, and she had no ocular complaints.
On physical examination, the patient’s corrected visual acuity was 20/30 in the right eye (pinhole to 20/25) and 20/20 in the left eye. Her pupils were round and reactive with no relative afferent pupillary defect. IOPs were 13 mm Hg in the right eye and 12 mm Hg in the left eye. Extraocular motility and confrontational visual fields were full in both eyes. Her slit lamp examination was remarkable for 2+ nuclear sclerotic cataracts in both eyes. A creamy elevated lesion was seen in the left eye, and fundus photos were taken and fluorescein angiography was performed on that eye (Figures 1 to 3).
Upon further questioning about the patient’s history, she stated that she was diagnosed with renal cell carcinoma in 2002 and had been treated for lung, liver and bone metastasis. She stated that she has been “cancer free” for 6 months. Her oncologist was notified of the ocular findings, and the patient underwent an MRI of the brain and orbits, as well as a CT of the chest, abdomen and pelvis. No other lesions were seen on MRI; however, on CT, new liver, lung and spinal lesions were seen, consistent with metastatic disease. The patient began chemotherapy treatment immediately.
Figure 1. Right eye: Flat 2.5 disc diameter-sized nevus in the superotemporal macula with drusen and no subretinal fluid/orange pigment. Localized retinal detachment repair with good cryotherapy at 2 o’clock.
Images: Thompson KG, Kitchens JW
Figure 2. Left eye: Creamy elevated 1.5 disc diameter lesion superiorly with central pigment and creamy flat 0.5 disc diameter lesion in macula not seen on early examinations or on fundus photograph from 2010.
Figure 3. There was hyperfluorescent speckling of the superior elevated lesion.
Discussion
Kyle G. Thompson
John W. Kitchens
Choroidal metastatic disease has been reported in a number of different primary cancers, including renal cell carcinoma. In a large survey of 520 eyes with uveal metastasis performed by Shields et al, the kidney was the site of the primary cancer in 2% of cases. The other locations were breast 47%, lung 21%, gastrointestinal tract 4%, skin 2%, prostate 2%, and other cancers 4%; 17% of cases never had the primary site established despite systemic evaluation. The survey also stated that the choroid is the most common site of uveal metastasis and that most eyes on average have two lesions.
Careful, regular ocular examinations should be performed in patients with a history of primary malignancy, even if asymptomatic, because the first manifestation of metastatic disease can be in the choroid. In this patient, early recurrent metastatic disease was discovered, allowing for earlier initiation of chemotherapy and maximizing a favorable potential outcome.