Kerala Journal of Ophthalmology

CASE REPORT
Year
: 2018  |  Volume : 30  |  Issue : 3  |  Page : 200--202

Serous macular detachments are not always benign


Thresika Uvaraj, Merie Mathew 
 Department of Ophthalmology, Amala Institute of Medical Sciences, Thrissur, Kerala, India

Correspondence Address:
Merie Mathew
Amala Institute of Medical Sciences, Amala Nagar, Thrissur - 680 555, Kerala
India

Abstract

The incidence of choroidal metastases from lung adenocarcinoma without a history of primary tumor detection was rarely reported. A 59-year-old male presented with diminution of vision in the left eye 10 days after starting the antitubercular treatment. The vision deteriorated dramatically, and ancillary tests revealed a metastatic lesion in the left eye from adenocarcinoma of the lung. This case report highlights the possibility of intraocular metastases in adults who present with symptoms of blurring of vision of short duration.



How to cite this article:
Uvaraj T, Mathew M. Serous macular detachments are not always benign.Kerala J Ophthalmol 2018;30:200-202


How to cite this URL:
Uvaraj T, Mathew M. Serous macular detachments are not always benign. Kerala J Ophthalmol [serial online] 2018 [cited 2019 Jun 25 ];30:200-202
Available from: http://www.kjophthal.com/text.asp?2018/30/3/200/247586


Full Text

 Introduction



Serous macular detachment (SMD) is a separation of neurosensory layer from retinal pigment epithelium (RPE) occurring at the macula. Although the exact mechanism of development is not known, it may occur in retinal or choroidal vascular leakage with RPE dysfunction. It occurs in a variety of benign and malignant conditions including choroidal hemangioma, choroidal granuloma, posterior scleritis, atypical central serous chorioretinopathy, amelanotic melanoma, and choroidal metastases with similar fundoscopic appearance.[1] The unique feature of our case reported is that the primary site of the tumor was not detected or suspected at the time of manifestation in the eye. The incidence of choroidal metastases from metastatic lung cancer was reported to be 2%–6.7%. Within the uvea, 88% of metastases are to the choroid, followed by metastases to the iris (9%), and ciliary body (2%).[2] Hence, this case report is significant for its rarity of presentation.

 Case Report



A 59-year-old healthy male was referred from pulmonology department with a history of defective vision of the left eye OS noticed for 3 days, to rule out drug toxicity. The patient was on antituberculous treatment for 10 days after core lung biopsy showing caseating granulomatous lesion in the right lower lobe. Ophthalmic evaluation revealed best-corrected visual acuity (BCVA) 6/9 in the OD and 6/12 in the OS. Color vision and the anterior segment examination were within normal limits in both eyes. OD fundus was normal. In OS, there was no vitritis; disc and vessels were normal with a dull macula. Near visual acuity of OD was N6 and OS was N10. Optical coherence tomography (OCT) macula OS showed a small SMD with foveal thickness of 370 microns; there was no underlying pigment epithelial detachment. Humphrey field analysis showed a central scotoma in the OS. The patient was prescribed anti-inflammatory eye drops and was advised to review after 1 week. After 1 week, his vision was progressively decreasing in the OS (BCVA 6/24). A repeat OCT was taken, and SMD was seen to be tripled with foveal thickness of 1078 microns [Figure 1]a. Detailed reexamination of the fundus showed a small yellowish raised flat lesion superotemporal to the disc with exudative retinal detachment all around involving the macula [Figure 1]b and [Figure 2]. With the suspicion of choroidal metastases/choroidal tubercle, the patient was referred to the higher center for further evaluation. Fundus fluorescein angiography (FFA) was done which showed hyperfluorescence increasing in the late phase with leakage [Figure 3]. Indocyanine green (ICG) angiogram was done which showed a hypofluorescent choroidal lesion with patchy staining of the surface of the lesion. There was no disc leakage or evidence of any inflammation [Figure 4]. All features were in favor of choroidal metastases, and hence, the patient was referred to pulmonologist to have a repeat biopsy from another site of lung lesion. A computed tomography (CT)-guided lung biopsy was taken, and histopathology report was suggestive of a moderately differentiated adenocarcinoma [Figure 5]. The patient was then referred to oncologist for further management.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}

 Discussion



In general, tumors that metastasize to the eye are carcinomas. Lung carcinoma is the second common primary site.[3],[4] Unlike carcinoma breast, lung secondaries are seen earlier. The uveal tract is the common site of metastases and is hematogenous. The most common route is through the pulmonary circulation. A small number of metastases do occur directly to the arterial system through Batson's vertebral plexus bypassing the pulmonary circulation.[5] Tumor emboli travel through carotid artery and reach the eye through ophthalmic artery. There is a predilection for OS due to the direct takeoff of the carotid artery on the left side.[3] After reaching ophthalmic artery, they reach the posterior choroid through posterior ciliary arteries which are numerous.[6] The tumor cells leave the circulation, embedded in highly vascular uveal stroma and proliferate. The common site of choroid involved is between macula and equator.[3] Submacular choroid and temporal fundus are more involved.[5]

Some points to distinguish metastatic carcinoma from primary choroidal melanoma are its site (posterior pole), infiltrative nature, flat or dome-shaped, creamy yellow color, often multifocal may be bilateral with large exudative retinal detachment with shifting fluid, rapid growth, and absence of dual circulation. In ultrasound B scan, choroidal metastases are characterized by a significantly lower height-to-base ratio than melanomas. In ultrasound A scan, a high-internal reflectivity is seen unlike melanoma. FFA, ICG, fine-needle aspiration biopsy, and color flow mapping (hypervascularity, lack of a “dominant vessel,” and typically have a “peripheral pattern” blood flow) also help to distinguish from other choroidal lesions.[2],[7],[8] In ICG angiography, choroidal metastasis shows hypofluorescence at the site of metastasis throughout the phases.[9] In FFA, the metastatic tumor will show early staining with fluorescein leakage into the lesion. Arterial phase of the FFA shows numerous collection areas of dyes in the choroid. Retinal vessels overlie the areas of dye retention.

Choroidal tuberculosis presents as multiple tubercles (0.3–3 mm) or solitary tuberculoma (2–3 disc diameter) at the posterior pole. They are usually yellowish gray or white with serous macular detachments and hemorrhages. Angiographically, tubercles are hypofluorescent initially with progressive hyperfluorescence in late phases. Tuberculoma shows early hyperfluorescence with leakage of dye around the margins in the late phase.[10] There are no typical angiogram findings for choroidal tuberculoma. On ICGA, hypofluorescent choroidal lesions are seen in all phases. Ultrasound B scan shows elevated mass with absence of scleral echo. In A scan, low internal reflectivity and high vascularity may simulate melanoma.[10] CT/X-ray chest and polymerase chain reaction of intraocular fluid are the confirmatory tests.

Patients with solitary intraocular metastases without the involvement of vital organs are surviving longer. Treatments include plaque radiotherapy (solitary metastases), external beam radiation therapy, and photodynamic therapy if detected early.[2],[7],[8] Bevacizumab, a potent monoclonal antibody, has also been employed for the treatment of choroidal metastases and has shown promising results.[2],[4],[7] In advanced cases, chemotherapy, immune therapy, and hormone therapy are recommended.

This case study concluded that a careful eye examination could be an important staging procedure in tumors known to involve the eye or adnexa which may be the initial site of metastases. Intraocular metastases should be considered in adults between fourth and seventh decades of life while evaluating patients with unexplained blurring of vision, uveitis, glaucoma, iris nodules, rubeosis iridis, and large exudative retinal detachment.

Acknowledgment

The authors would like to acknowledge the valuable help of Dr. Ajith TA, Professor, Department of Biochemistry, Amala Institute of Medical Sciences, Thrissur, Kerala, India, during the preparation of this manuscript.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Salem MB, Chebbi A, Rouatbi A, Korbi M, Zbiba W, Bouguila H. Pitfalls in the diagnosis of choroidal tumors: 3 case reports of choroidal masses. Research 2017;4:2264. DOI//dx.doi.org/10.13070/rs.en.4.2264.
2Smith A. Choroidal Metastases – EyeWiki. Eyewiki.aao.org; 2018. Available from: http://www.eyewiki.aao.org/Choroidal_Metastases. [Last accessed on 2018 Jan 25].
3Dobree J, Duke-Elder S. System of Ophthalmology. London: Henry Kimpton; 1967.
4Giuliari GP, Sadaka A. Uveal metastatic disease: Current and new treatment options (review). Oncol Rep 2012;27:603-7.
5Jakobiec F, Albert D. Principles and Practice of Ophthalmology. 2nd ed. Philadelphia: W.B. Saunders; 2000.
6Ryan S, Wilkinson C. Retina. 4th ed. St. Louis, Missouri: Mosby; 2006.
7Arepalli S, Kaliki S, Shields CL. Choroidal metastases: Origin, features, and therapy. Indian J Ophthalmol 2015;63:122-7.
8Bowling B. Kanski's Clinical Ophthalmology. 8th ed. Edinburgh: Elsevier; 2016.
9Pal BP, Garge S, Khetan V. Choroidal melanoma: A short review with an Indian perspective. Oman J Ophthalmol 2017;10:135-44.
10Yanoff M, Duker JS. Ophthalmology. 4th ed. St. Louis, Missouri: Mosby; 1999.