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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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CASE REPORT
Year : 2021  |  Volume : 28  |  Issue : 3  |  Page : 193-195  

Unusual manifestation of choroidal metastasis as late presentation of treated lung cancer with floaters


1 Department of Ophthalmology, Salisbury District Hospital, SP2 8BJ, Salisbury, UK
2 Department of Ophthalmology, Rotherham District General Hospital, S60 2UD, Rotherham, UK
3 Jiggins Lane Medical Centre, BE32 3LE, Birmingham, UK
4 Medical Doctor, Southampton, UK

Date of Submission02-Sep-2021
Date of Acceptance24-Nov-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Dr. Mohamed Osman
Department of Ophthalmology, Salisbury District Hospital, 46 English Road, Southampton SO15 8QF
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/meajo.meajo_255_21

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   Abstract 


Metastatic tumors to the choroid are the most common intraocular malignancies. Choroidal metastasis from lung cancer is uncommon. Visual affection or other ocular manifestations as the initial clinical presentation of lung cancer primarily are rare. We report a case of a 71-year-old female patient presented with eye floaters in her right eye. Examination of the right eye visual acuity of 20/30 and fundoscopy revealed a pale choroidal mass superior to optic disc. Ocular coherent tomography showed subretinal fluid at the site of choroidal lesion. The patient is currently treated with radiotherapy and chemotherapy for secondary metastasizes in liver. In spite of floaters is very common nonserious symptoms in ophthalmology practice, but it should be taken seriously to rule out lifesaving condition.

Keywords: Choroidal metastasis, floaters, lung cancer


How to cite this article:
Osman M, Alwash B, Elkady A, Zeineldin S. Unusual manifestation of choroidal metastasis as late presentation of treated lung cancer with floaters. Middle East Afr J Ophthalmol 2021;28:193-5

How to cite this URL:
Osman M, Alwash B, Elkady A, Zeineldin S. Unusual manifestation of choroidal metastasis as late presentation of treated lung cancer with floaters. Middle East Afr J Ophthalmol [serial online] 2021 [cited 2022 Jul 4];28:193-5. Available from: http://www.meajo.org/text.asp?2021/28/3/193/334626




   Introduction Top


Intraocular metastasis is commonly seen in the posterior pole of the eye. Controlled figures elaborated from screening studies in patients with metastatic cancer confirmed with pathological studies propose that choroidal metastasis is the most frequent intraocular tumor.[1] Lung cancer is the most common cancer in males and is the leading cause of death in poor countries.[2] Clinical reports of symptomatic intraocular metastasis from lung cancer are rare and often confined to single cases. Symptomatic choroidal metastasis can represent the first sign of lung cancer. It often presents as a unilateral solitary lesion and thus is an important differential diagnosis to choroidal melanoma. Based on our findings in our case, we present a patient with unilateral floaters with almost mild decrease in visual acuity. Symptomatic choroidal metastasis from lung cancer may become clinically apparent in only a minority of patients. Floaters in old patients should be taken seriously.


   Case Report Top


A 71-year-old female presented to optometrist complaining of floaters in her right eye for 3-week duration. She has no past ophthalmic problems and never had any ocular surgical procedures. After consultation by general practitioner, she was referred to secondary care ophthalmology department.

Examination of the right eye showed that visual acuity of 20/30, normal intraocular pressure, emmetropia, and fundoscopy revealed a mass with a size of 6 discs diameter superior to optic nerve. Examination of the left eye was unremarkable with 20/20 vision. Proper history was taken from the patient about any previous illness, trauma, radiation, and chemotherapy. The patient gave a history of treatment of lung cancer 7 years ago that had been cured. Ocular coherent tomography of the right eye was requested, which showed subretinal fluid at the site of choroidal lesion [Figure 1]. The clinical presentation and imaging finding raised suspicion of metastasis. Urgently, the patient was referred to oncology department and medical team for tumor screening which revealed liver metastasis. The patient is currently treated with radiotherapy and chemotherapy for secondary metastasizes in the liver and eye.
Figure 1: Optical coherence tomographic finding of subretinal fluid and chordal mass

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   Discussion Top


Majorities of floaters are caused by moving particles on hold in the vitreous cavity, a highly acellular extracellular matrix consisting predominantly of water.[3] The awareness of floaters is a commonly stated phenomenon in ophthalmic patients, and floater symptoms are a common cause of acute appearance to emergency eye services.[4] On the basis of the symptoms alone, it is not possible to determine the etiology of floaters; in our patient, meticulous ocular examination revealed a choroidal mass that may be not related to the symptom. Some cases of floaters are associated with specific mechanical events such as retinal breaks and posterior vitreous detachment.[5] In spite of most cases of floaters are considered benign, our patient diagnosed metastasis for serious lesion.

Ergenc et al. presented a 67-year-old male patient with bilateral choroidal metastases from lung adenocarcinoma coming to the ophthalmologist complaining of blurred vision.[6]

In consistent to our case, Asma Migaou presented a 48-year-old female with painless loss of vision left eye as initial presentation of metastasis to lung cancer.[7]

The choroid is the most common site for ocular secondary metastasis as it is rich in vascular and oxygen supply. Most common site of metastasis in the choroid is the postequatorial region as in our case, with the development of subretinal fluid. Unfortunately, choroidal metastasis is usually considered a late poor prognostic sign.[8] The symptoms of choroidal metastasis vary between decreased visual acuity and less common manifestations include flashes and pain. Choroidal metastasis can be misinterpreted as primary original tumor. Das et al.[9] reported a case of adenocarcinoma lung in a 42-year-old female patient with initial presentation of decreased vision due to retinal detachment as a result of choroidal metastasis. In our patient, the main symptom was floater but visual acuity was not affected significantly.

The treatment of choroidal metastasis depends on how well or unwell the patient is number, location, and site of the tumor. For example, observation is preferred in unwell patients but in other cases chemotherapy, immunotherapy and whole eye radiation are preferable treatment options. Furthermore, plaque radiotherapy, transpupillary radiotherapy, or photodynamic therapy is the treatment of choice for solitary metastasis. It is widely accepted that systemic chemotherapy can control the tumor. However, focal therapy held better results, especially when the tumor is causing visual loss or enucleation if it is a blind painful eye.

An important learning point from our study is that our patient's sight could have been at risk if any delay of diagnosis. Nonspecific eye symptoms and complaints can be misleading as the cause could be sinister rather than simple. In brief, our recommendation is that a 2-week urgent referral should be done for all cancer patients presenting with nonspecific eye complaints to rule out secondary metastasis.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kreusel KM, Bechrakis NE, Krause L, Wiegel T, Foerster MH. Incidence and clinical characteristics of symptomatic choroidal metastasis from breast cancer. Acta Ophthalmol Scand 2007;85:298-302.  Back to cited text no. 1
    
2.
Mauget-Faÿsse M, Gambrelle J, Quaranta-El Maftouhi M, Moullet I. Photodynamic therapy for choroidal metastasis from lung adenocarcinoma. Acta Ophthalmol Scand 2006;84:552-4.  Back to cited text no. 2
    
3.
Bishop PN. Structural macromolecules and supramolecular organisation of the vitreous gel. Prog Retin Eye Res 2000;19:323-44.  Back to cited text no. 3
    
4.
Hollands H, Johnson D, Brox AC, Almeida D, Simel DL, Sharma S. Acute-onset floaters and flashes: Is this patient at risk for retinal detachment? JAMA 2009;302:2243-9.  Back to cited text no. 4
    
5.
Schweitzer KD, Eneh AA, Hurst J, Bona MD, Rahim KJ, Sharma S. Predicting retinal tears in posterior vitreous detachment. Can J Ophthalmol 2011;46:481-5.  Back to cited text no. 5
    
6.
Ergenc H, Onmez A, Oymak E, Tanriseven R, Celik E, Onmez FE, et al. Bilateral choroidal metastases from lung adenocarcinoma: A case report. Case Rep Oncol 2016;9:530-6.  Back to cited text no. 6
    
7.
Migaou A, Ben Saad A, Joobeur S, Ben Abdeljelil N, Zina S, Cheikh Mhammed S, et al. Choroidal metastasis as the initial presentation of lung adenocarcinoma: A case report. Respir Med Case Rep 2020;29:100992.  Back to cited text no. 7
    
8.
Arepalli S, Kaliki S, Shields CL. Choroidal metastases: Origin, features, and therapy. Indian J Ophthalmol 2015;63:122-7.  Back to cited text no. 8
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9.
Das SK, Sahoo TK, Parija S, Majumdar SK, Parida DK. Choroidal metastasis as initial presentation in adenocarcinoma of lung: A case report. J Clin Diagn Res 2017;11:XD04-6.  Back to cited text no. 9
    


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