Frequency of asymptomatic choroidal metastasis in patients with disseminated breast cancer: results of a prospective screening programme

AIM—To determine the frequency of visually asymptomatic choroidal metastasis in patients with disseminated breast cancer and its dependence on the incidence of metastasis by number and site of other organ metastases.
METHODS—From January 1995 until April 1997 120 patients irradiated for disseminated breast cancer underwent ophthalmological screening for choroidal metastasis. No patient was symptomatic for ocular disease. 68 out of 120 patients were found to have metastases in one organ and 52 patients had metastases in more than one organ. 80% of the patients had bone metastases, 25% lung metastases, 22% liver metastases, 15% brain metastases, and 22% had metastases in other organs.
RESULTS—Six patients (5%) were found to have asymptomatic choroidal metastases. Five patients had unilateral and one patient bilateral metastases. 52 patients with more than one involved organ had a significantly higher risk for asymptomatic choroidal metastasis (6/52, 11%) than 68 patients with metastases in only one organ (0/68) (p=0.006). In univariate analysis a significantly higher risk was seen for patients with lung metastases (14% choroidal metastases versus 2% in patients without lung metastases, p=0.03) and for patients with brain metastases (17% choroidal metastases versus 3% in those without brain metastases, p=0.04).
CONCLUSION—In disseminated breast cancer the incidence of asymptomatic choroidal metastases was 5% and increased to 11% when more than one organ was involved in metastatic spread. Risk factors for choroidal metastases were dissemination of disease in more than one organ and the presence of lung and brain metastases.

Keywords: choroidal metastasis; breast cancer; screening programme     

Intravitreal bevacizumab in the successful management of choroidal metastases secondary to lung and breast cancer unresponsive to systemic therapy: a case series

Purpose

Management of choroidal metastases is commonly with systemic chemotherapy; however, if tumours are refractory to treatment and vision is endangered, local therapy modalities are feasible. A novel option is the use of intravitreal bevacizumab. This report presents three cases of choroidal metastatic tumours secondary to lung and breast cancer treated with intravitreal bevazizumab.

Patients and methods

Three patients with choroidal metastases secondary to lung and breast tumours were treated at the Ophthalmology Unit, University of Rome ‘Sapienza'', S.Andrea Hospital from January 2009 to August 2012. All patients developed vision loss with diagnosis of chorioidal metastasis during systemic chemotherapy. Off label intravitreal bevacizumab treatment was performed with two 1.25 mg injections in two patients and four injections in one patient at 30-day intervals.

Results

Vision improved, subretinal fluid resolved, and choroidal tumour regression was obtained in all cases. Follow-up was 6, 9, and 12 months and there were no complications related to treatment.

Conclusions

Intravitreal bevacizumab administration represented an efficacious therapeutic option with rapid effect in the treatment of choroidal metastatic tumours unresponsive to systemic therapy. It can have a role in the management of these tumours by preventing vision loss and improving the quality of life of patients.     

Review of spectral domain enhanced depth imaging optical coherence tomography of tumors of the choroid

Background:Spectral domain enhanced depth imaging optical coherence tomography (EDI-OCT) can provide anatomic localization of intraocular tumors.Aims:The aim was to identify topographical and intrinsic patterns of choroidal tumors on EDI-OCT.Results:Using EDI-OCT, choroidal nevus displayed a smooth, dome-shaped topography with overlying retinal pigment epithelium alterations, drusen, and occasional subretinal cleft demonstrating photoreceptor loss. Small choroidal melanoma showed smooth, moderately dome-shaped topography, commonly with overlying shallow subretinal fluid that often depicted “shaggy” photoreceptors. Choroidal metastasis showed a minimally “lumpy, bumpy” surface topography and with overlying subretinal fluid and shaggy photoreceptors. Choroidal hemangioma showed a smooth, dome-shaped topography, with expansion of the affected small, medium, and large choroidal vessels. Choroidal lymphoma showed varying topography with increasing tumor thickness as “flat, rippled, or undulating (seasick)” surface. Choroidal osteoma displayed a smooth undulating surface with visible intralesional horizontal lines suggestive of bone lamellae and occasional horizontal and vertical tubules with intralesional “spongy” flecks. Choroidal melanocytosis appeared as uniformly thickened choroid with increased stromal density surrounding the normal choroidal vascular structures.Conclusions:Enhanced depth imaging-OCT can depict characteristic patterns that are suggestive of various choroidal tumors.     

Decreased prevalence of asymptomatic choroidal metastasis in disseminated breast and lung cancer: argument against screening

AIM: To determine the frequency of visually asymptomatic choroidal metastases in patients with disseminated breast and lung carcinomas in order to establish optimal patient management policies. METHODS: All patients with confirmed metastatic disease treated in our institution between January 2002 and December 2003 were invited to undergo a funduscopic examination and a B-scan ultrasound evaluation. RESULTS: Of the 169 study participants, 77 had breast cancer (64 with metastases in one organ and 13 with multiple-organ involvement) and 92 had lung cancer (85 with metastases in one organ and 7 with multiple-organ involvement). No patient with metastatic breast cancer and two patients with metastatic lung disease (each with multiple-organ involvement) were found to have choroidal metastases. The choroidal metastases were detected by both the funduscopic and ultrasound examinations. CONCLUSIONS: The 2.17% incidence of choroidal metastasis in disseminated lung cancer and the 0% incidence in disseminated breast cancer speaks against the practicality of screening for early detection of choroidal metastasis among these patients, even though it would lead to early implementation of appropriate, often vision saving, therapeutic management. Its low incidence probably testifies to progress achieved by enhanced systemic oncological treatment policies that have been introduced into routine patient management over the past few years.     

Choroidal metastasis: case reports and review of the literature.

BACKGROUND: Choroidal metastases are recognized as the most common intraocular malignancy. Their diagnosis has become more common due to increased emphasis on comprehensive eye examinations for cancer patients and the improved life expectancy of patients with metastatic disease. They are most prevalent in female patients with breast cancer and male patients with lung cancer. METHODS: A thorough fundus examination, coupled with the use of A-scan and B-scan ultrasonography, will aid in their diagnosis. There are many ways of treating these tumors, including radiation therapy, chemotherapy, and monitoring. CASE REPORTS: Two case reports of patients diagnosed with choroidal metastases are discussed. Case 1 involved a patient with lung cancer who manifested a large bullous exudative retinal detachment due to an underlying choroidal metastasis. Case 2 dealt with treatment of a patient with metastatic transitional cell cancer who manifested a shallow exudative retinal detachment caused by a choroidal metastasis. CONCLUSIONS: Due to progress of chemotherapeutic medications, the number of patients who manifest choroidal metastases will continue to increase. It is essential for the practitioner to be able to recognize this disease process to prevent visual loss and institute referral for proper treatment for metastatic disease.     

Uveal metastasis from breast cancer in 264 patients

PURPOSE: Breast cancer is an increasingly important health problem in women and is the most common tumor to metastasize to the uvea. This study was designed to evaluate the clinical features, management, and prognosis of patients with uveal metastasis from breast cancer. DESIGN: Retrospective interventional case series. METHODS: We retrospectively reviewed 264 consecutive patients with uveal metastasis from breast cancer. We assessed the clinical features of the patient and tumor at the time of presentation, management, and prognosis. Kaplan-Meier survival estimates were used to analyze the probability of death as a function of time. RESULTS: Uveal metastasis was the initial manifestation of breast cancer in seven patients (3%) and the first systemic metastatic site of previously diagnosed breast cancer in 43 (16%). Associated with uveal metastasis, optic disk metastasis was found in 13 patients (5%), eyelid metastasis in one patient (1%), and conjunctival and orbital in one patient (<1%). Of 264 patients with uveal metastasis, 225 (85%) had choroidal metastasis, eight (3%) iris metastasis, two (<1%) ciliary body metastasis, and 29 (11%) had metastasis in multiple uveal sites. In the 264 patients with uveal metastasis, the most common symptom was blurred vision in 197 patients (88%), floaters in 15 (5%), photopsia in 12 (5%), and 19 (7%) were asymptomatic. The uveal metastases were bilateral in 99 patients (38%) and unilateral in 165 (62%). In 55 (56%) of the 99 bilateral cases, a uveal metastasis was found in the asymptomatic fellow eye during follow-up examination. External beam radiotherapy was used in 137 patients with uveal metastasis (52%), providing tumor control in 116 patients (85%) at a mean follow-up of 21 months. Using Kaplan-Meier estimates, survival rates of all patients with uveal metastasis from breast cancer was 65% at 1-year, 34% at 3-year, and 24% at 5-year follow-up. CONCLUSIONS: Patients with uveal metastasis from breast cancer presented to ophthalmologists with visual symptoms in 93% of cases. However, asymptomatic metastases were commonly detected in the fellow eye. Local ocular tumor control was excellent with current therapies. However, systemic prognosis for all patients, including those who had been treated with different management options, was poor with survival rates of 65% at 1-year and 24% at 5-year follow-up.     

PresbyLASIK: A review of PresbyMAX,Supracor, and laser blended vision: Principles,planning, and outcomes

PresbyLASIK is one of the most commonly used modalities of surgical correction in presbyopes with no cataract. Unlike monovision procedures, both the eyes are adjusted for near and distance, providing a good stereopsis. This works by creating a corneal multifocality and increasing the depth of focus. Most techniques of presbyLASIK currently employ hybrid methods, i.e., a component of monovision added on to a multifocal corneal ablation. Choosing an appropriate proportion of these two components according to the patients'' requirements and meticulous patient selection are key to obtaining desirable outcomes. Being corneal-based procedures, presbyLASIK has shown to be reversible. Thorough updated knowledge of the different presbyLASIK procedures, their principles and outcomes based on previous studies is required before a refractive surgeon plans to start providing presbyLASIK services. We performed a comprehensive search on PubMed with the keywords “Presbyopia surgery,” “PresbyLASIK” “PresbyMAX,” “Supracor,” and “Custom-Q.” In this review article, we have explained the principles of the various presbyLASIK procedures, appropriate patient selection and planning on the devices with examples, and summarized the previously published outcomes of these techniques.     

Metastatic adenocarcinoma of the cervix presenting as a choroidal mass: A case report and review of literature of cervical metastases to the eye

Cervical cancer is the most common cancer among females in India. Cervical cancer usually spreads by local extension and through the lymphatic drainage to the lymph nodes. Hematogenous spread, the mechanism responsible for distant metastases, is rarely seen in cervical malignancies. In this communication, we report a case of a 45-year-old woman who presented with unilateral decrease in vision of 3 months duration. She was found to have a serous retinal detachment with underlying diffuse, subretinal yellowish-cream colored infiltrates in the right eye, suspicious of choroidal metastases. Systemic evaluation showed disseminated systemic metastases arising from a primary adenocarcinoma of the cervix. In this communication, we review all the documented cases of metastases to the eye and adnexa arising from cervical cancer and their clinical characteristics. Unilateral choroidal metastasis arising from an adenocarcinoma of the cervix is extremely rare with only one previous documented case. Although uncommon, choroidal metastasis may be the presenting feature of primary cervical malignancy. Furthermore, cervical malignancy must be ruled out in women who present with orbital or choroidal metastases arising from unknown primary.     

Emerging treatments for choroidal metastases

It has been over a century since Perls described the first case of choroidal metastasis. For the next six decades only 230 cases were described in the literature. Today, however, ocular metastasis is recognized as the most common intraocular malignancy. Thanks to recent advances in treatment options for metastatic disease, patients are living longer, and choroidal metastases will become an increasingly important issue for oncologists and ophthalmologists alike. We summarize the current knowledge of choroidal metastases and examine their emerging systemic and local therapies. Targeted therapies for metastatic lung, breast, and colon cancer—the most common causes of choroidal metastases—are reviewed in detail with the goal of identifying the most effective treatment strategies.     

Systemic chemotherapy and tamoxifen induced regression of choroidal metastasis from a breast carcinoma in a male

We report a case of a 55-year-old male patient with breast carcinoma, who developed choroidal metastasis. The patient had undergone mastectomy for carcinoma of right breast, five years ago. The patient was advised close follow-up for the left eye, as he was already on tamoxifen therapy (started a month ago) for spinal metastasis. On last follow-up, a year later, the choroidal lesion had completely scarred, with no recurrences. Systemic hormonal therapy like tamoxifen given for the breast primary and other systemic metastases may cause regression of the choroidal metastasis, thereby avoiding ocular radiotherapy. Medline search revealed only one published case of regression of choroidal metastasis from a male breast primary, on tamoxifen therapy.     

Choroidal metastasis from submandibular salivary gland adenoid cystic carcinoma.

A case of choroidal metastasis from an adenoid cystic carcinoma ofsubmandibular salivary gland is described. A 50-year-old woman with loss of vision in her left eye for 1 week was evaluated clinically, radiologically, and pathologically. A fundus image of the left eye showed an amelanotic, plateau-shaped choroidal mass measuring 17 x 12 X 4 mm with overlying exudative retinal detachment. A choroidal biopsy was consistent with metastatic adenoid cystic carcinoma from her submandibular salivary gland treated 5 years previously. She was treated with external beam radiotherapy but developed liver and lung metastases 3 months later and died within 1 month. All of the metastases demonstrated a basaloid histologic variant of adenoid cystic carcinoma that is known for its aggressive potential. Salivary gland carcinoma rarely metastasizes to the choroid; however, evaluation of patients with this carcinoma should include ophthalmic examination.     

Retinoblastoma: Achieving new standards with methods of chemotherapy

The management of retinoblastoma (RB) has dramatically changed over the past two decades from previous radiotherapy methods to current chemotherapy strategies. RB is a remarkably chemotherapy-sensitive tumor. Chemotherapy is currently used as a first-line approach for children with this malignancy and can be delivered by intravenous, intra-arterial, periocular, and intravitreal routes. The choice of route for chemotherapy administration depends upon the tumor laterality and tumor staging. Intravenous chemotherapy (IVC) is used most often in bilateral cases, orbital RB, and as an adjuvant treatment in high-risk RB. Intra-arterial chemotherapy (IAC) is used in cases with group C or D RB and selected cases of group E tumor. Periocular chemotherapy is used as an adjunct treatment in eyes with group D and E RB and those with persistent/recurrent vitreous seeds. Intravitreal chemotherapy is reserved for eyes with persistent/recurrent vitreous seeds. In this review, we describe the various forms of chemotherapy used in the management of RB. A database search was performed on PubMed, using the terms “RB,” and “treatment,” “chemotherapy,” “systemic chemotherapy,” “IVC,” “IAC,” “periocular chemotherapy,” or “intravitreal chemotherapy.” Relevant English language articles were extracted, reviewed, and referenced appropriately.     

Presumed eccrine carcinoma metastatic to the choroid

The purpose of this article is to describe a patient with presumed choroidal metastasis from an eccrine adenocarcinoma of the scalp. A 45-year-old Caucasian woman presented with decreased visual acuity. Ophthalmologic examination was unremarkable. Her past medical history was significant for eccrine carcinoma of the scalp. The patient developed bilateral cervical lymph node metastases, and received chemotherapy and radiotherapy. She had recurrence of the scalp lesion and developed bone metastasis. The patient was again referred to an ophthalmologist owing to reduced visual acuity. Multiple choroidal metastases were detected in right eye, and one metastatic lesion in left eye. The patient passed away 2 months after choroidal metastases. This is the first report of choroidal metastases from an eccrine carcinoma. This is a rare aggressive neoplasm with poor outcome in most cases of metastatic disease, and in this case report, uveal metastasis was indicative of poor prognosis.     

Choroidal metastases and choroidal melanomas: comparison of ultrasonographic findings

AIMS—The purpose of the study was to analyse, whether the shape and the height to base ratio in B-scan ultrasonography are appropriate to differentiate choroidal melanomas from metastases.
METHODS—Between 1991 and 1996 16 eyes of 16 patients with choroidal metastases from breast carcinomas and 66 eyes of 66 patients with choroidal melanomas were evaluated ultrasonographically. The diagnosis of choroidal melanoma has been confirmed histologically in all eyes. Irradiated tumours were excluded from the study. Fisher's exact test and χ² test were used for statistical analysis.
RESULTS—Choroidal metastases demonstrated a significantly lower height to base ratio in B-scan (mean 0.18, SD 0.08) than melanomas (mean 0.6 (0.16); p < 0.001). A polygonal tumour surface was significantly more frequent in metastases (13 out of 16 metastases and in six out of 66 melanomas, p < 0.001). A choroidal excavation could be demonstrated in 38 melanomas and in no metastatic tumour (p < 0.001). The reflectivity was significantly higher in metastases than in melanomas.
CONCLUSION—The combined use of height to base ratio and reflectivity enables a highly significant discrimination between choroidal melanomas and metastases from the breast, thus probably constituting appropriate variables for the clinical differentiation.

Keywords: choroidal melanoma; choroidal metastasis; ultrasonography     

Ocular manifestations of cancer

Cancer may affect the eye and orbit as a direct result of metastatic neoplastic infiltration, compression, or circulating antibodies involving paraneoplastic retinal degeneration. A metastatic tumor to the uvea is the most common form of an intraocular metastatic process. The choroid is the most common site for uveal metastasis; metastases to the ciliary body, iris, retina, optic disk, and vitreous are rare. Approximately one-third of patients have no history of primary cancer at the time of ocular diagnosis. Breast and lung carcinomas for women and lung and gastrointestinal carcinomas for men most commonly metastasize to the eye and orbit. The short-term prognosis for vision is usually good after an individualized therapeutic approach (chemotherapy, hormonal therapy, external beam radiotherapy, or plaque radiotherapy), but the systemic prognosis is poor. The visual paraneoplastic syndromes encompass several distinct clinical and pathological entities including carcinoma-associated retinopathy (CAR), melanoma-associated retinopathy (MAR), and bilateral diffuse melanocytic uveal proliferation (BDUMP). The CAR syndrome affects photoreceptors, MAR is thought to affect bipolar cell function, and BDUMP targets the uveal tract. Identification of circulating antibodies against retinal proteins (recovering, 23-kDa retinal protein; 46-kDa and 60-kDa retinal proteins) serves to recognize the paraneoplastic nature of the patient's symptoms, which frequently develop before the cancer is diagnosed. Anecdotal therapeutic responses are described after systemic steroids, immunoglobulin injection, and plasmapheresis. Recognition of their visual symptoms and ocular findings should alert the ophthalmologist to the possibility of cancer and systemic evaluation should be pursued.     

Normative data for optical coherence tomography in children: a systematic review

The purpose of this study is to systematically review the reported data of normal optical coherence tomography (OCT) results in the paediatric population. A systematic literature search was performed using the PubMed, Embase, and Web of Science databases, using the keywords “optical coherence tomography”; “normative data” or “healthy eyes”; “children” or “paediatric population”. Studies with at least 50 participants were included, irrespective of the OCT equipment employed. We excluded the OCT angiography studies or the studies investigating the choroidal thickness. Seventy-four studies were included in the final analysis and information on study design, number of participants, demographic characteristics, type of OCT equipment, OCT parameters and results was collected. Due to the high variability of OCT instruments and parameters used, a meta-analysis was not feasible. We report the normative values for the peripapillary retinal nerve fibre layer thickness and the macular retinal thickness for each ETDRS quadrant, as provided by the studies included in the present analysis. We also report the influence of ethnicity, age, gender, eye laterality, ISNT rule, spherical equivalent, and axial length on OCT results.Subject terms: Paediatrics, Medical imaging, Biomarkers     

Treatment options for atypical optic neuritis

Context:Optic neuritis (ON) is defined as inflammation of the optic nerve and can have various etiologies. The most common presentation in the US is demyelinating, or “typical” ON, usually associated with multiple sclerosis. This is in contrast to “atypical” causes of ON, which differ in their clinical presentation, management, and prognosis. These atypical cases are characterized by lack of eye pain, exudates, and hemorrhages on exam, very severe, bilateral or progressive visual loss, or with failure to recover vision.Aims:The aim was to describe the clinical presentations of atypical ON and their treatments.Results:Types of atypical ON identified include neuromyelitis optica, autoimmune optic neuropathy, chronic relapsing inflammatory optic neuropathy, idiopathic recurrent neuroretinitis, and optic neuropathy associated with systemic diseases. Atypical ON usually requires corticosteroid treatment and often will require aggressive immunosuppression.Conclusions:Unlike demyelinating ON, atypical ON requires treatment to preserve vision.     

Prognostication in eye cancer: the latest tumor,node, metastasis classification and beyond

The tumour, node, metastasis (TNM) classification is a universal cancer staging system, which has been used for five decades. The current seventh edition became effective in 2010 and covers six ophthalmic sites: eyelids, conjunctiva, uvea, retina, orbit, and lacrimal gland; and five cancer types: carcinoma, sarcoma, melanoma, retinoblastoma, and lymphoma. The TNM categories are based on the anatomic extent of the primary tumour (T), regional lymph node metastases (N), and systemic metastases (M). The T categories of ophthalmic cancers are based on the size of the primary tumour and any invasion of periocular structures. The anatomic category is used to determine the TNM stage that correlates with survival. Such staging is currently implemented only for carcinoma of the eyelid and melanoma of the uvea. The classification of ciliary body and choroidal melanoma is the only one based on clinical evidence so far: a database of 7369 patients analysed by the European Ophthalmic Oncology Group. It spans a prognosis from 96% 5-year survival for stage I to 97% 5-year mortality for stage IV. The most accurate criterion for prognostication in uveal melanoma is, however, analysis of chromosomal alterations and gene expression. When such data are available, the TNM stage may be used for further stratification. Prognosis in retinoblastoma is frequently assigned by using an international classification, which predicts conservation of the eye and vision, and an international staging separate from the TNM system, which predicts survival. The TNM cancer staging manual is a useful tool for all ophthalmologists managing eye cancer.     

The management of metastases to eye and orbit from carcinoma of the breast

This report describes 11 patients who developed visual symptoms due to choroidal or orbital metastases from carcinoma of the breast. All patients were treated using palliative radiotherapy with regression of metastases in five of six patients (83%) having choroidal involvement and three of five patients (60%) having orbital metastases. There were no complications due to radiotherapy. All these patients had advanced metastatic breast cancer with poor survival following development of orbital or choroidal metastases.     

The management of metastases to eye and orbit from carcinoma of the breast

This report describes 11 patients who developed visual symptoms due to choroidal or orbital metastases from carcinoma of the breast. All patients were treated using palliative radiotherapy with regression of metastases in five of six patients (83%) having choroidal involvement and three of five patients (60%) having orbital metastases. There were no complications due to radiotherapy. All these patients had advanced metastatic breast cancer with poor survival following development of orbital or choroidal metastases.