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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 57  |  Issue : 1  |  Page : 74-76

Find us in fundus


1 Retina Services, Regional Institute of Ophthalmology and Government Ophthalmic Hospital, Chennai, Tamil Nadu, India
2 Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India

Date of Web Publication10-Jun-2019

Correspondence Address:
Dr. M Sivakami
F1, 872, 17th Main Road, Anna Nagar, Chennai - 600 040, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_15_19

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  Abstract 


Intraocular manifestations of malignancies and lesions elsewhere in the body are widely reported. The ophthalmic features can be due to metastasis in case of malignancy or due to the secondary effects of the lesions causing hematological or neurological complications. On a few occasions, the ocular features predominate and even precede the characteristic features pertaining to the underlying conditions. In such cases, an ophthalmologist can be the first clinician to encounter the patients. The ocular presentations can be bizarre or even misleading, but on careful history elicitation and examination could unveil life-threatening diseases lying hidden elsewhere inside the human body. Here, we present two case reports, where the ocular features helped in the diagnosis of primary pathology elsewhere.

Keywords: Choroidal detachment, disc edema, intracranial, leukemia, malignancy, metastasis, retinal detachment


How to cite this article:
Sivakami M, Parveen H S, Babu M A. Find us in fundus. TNOA J Ophthalmic Sci Res 2019;57:74-6

How to cite this URL:
Sivakami M, Parveen H S, Babu M A. Find us in fundus. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2019 Aug 23];57:74-6. Available from: http://www.tnoajosr.com/text.asp?2019/57/1/74/259876




  Introduction Top


“To live is to incur the risk of carcinoma,” wrote Robbins, in his textbook of pathology, after understanding the incidence, course, and outcome of malignancies. The diagnosis and management of any malignancy remain a challenge. A vast majority of malignancies manifest with atypical presentations and ophthalmologists can play a vital role in their diagnosis.

We present the case reports of two patients who had unnoticed but established malignancies. Both the patients presented to an ophthalmologist first, with the complaints of decreased vision, little did they know that it was just the tip of the iceberg.


  Case Reports Top


Case 1

A 50-year-old male presented with profound loss of vision in both the eyes of 1-week duration. There was no history of pain, redness, photophobia, or headache. He had been treated for pulmonary tuberculosis before 5 years. He also had ischemic heart disease and a right-sided residual hemiparesis.

His vision OU was only light perception. He had bilateral sluggishly reacting pupils and Grade-2 nuclear sclerosis of the lens. Fundus examination of both the eyes revealed massive disc edema with splinter hemorrhages, arteriolar attenuation, and dot-blot hemorrhages in the background retina [Figure 1]a and [Figure 1]b. OU intraocular pressures were normal. B-scan ultrasonography did not show anything more than bilateral disc edema and choroidal thickening. Blood pressure, lipid profile, serum glucose, and renal function tests were within the normal limits. Except for a raised erythrocyte sedimentation rate, the complete hemogram reports were normal. Computed tomography of the brain showed a hyperdense lesion with surrounding edema in the left parieto-occipital region and cerebellar region with midline shift to the right side [Figure 2]. The patient was referred to a neurologist for further evaluation and management.
Figure 1: (a and b) OD showing massive disc edema, splinter hemorrhages, arteriolar attenuation and dot-blot hemorrhages in the background retina

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Figure 2: Computed tomography of the brain cuts showing hyperdense lesion with surrounding edema in the left parieto-occipital region and cerebellar region with midline shift to the right side

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Case 2

A 65-year-old male presented with the complaints of sudden loss of vision in both eyes, chronic fever, and lethargy of 3-week duration. On examination, the patient looked frail and anemic. He had generalized lymphadenopathy and hepatosplenomegaly.

His visual acuity was counting fingers close to face in the right eye and perception of hand movements in the left eye. He had bilateral sluggishly reacting pupils and Grade 2 nuclear sclerosis of the lens. OU intraocular pressures were normal. Fundus examination followed by B-scan ultrasonography of the right eye revealed serous retinal detachment (SRD) and choroidal detachment (CD) and that of the left eye showed disc edema with peripapillary hemorrhages and subretinal hemorrhages, SRD, and CD [Figure 3]a, [Figure 3]b, [Figure 3]c. There was no evidence of secondaries. Complete hemogram revealed a markedly raised WBC count with predominant lymphocytosis. A peripheral blood smear showed a picture suggestive of chronic lymphocytic leukemia (CLL) with microcytic hypochromic anemia.
Figure 3: (a) Fundus picture OD showing serous retinal detachment, (b) fundus pictures OS showing disc edema, peripapillary and subretinal hemorrhages and serous retinal detachment, (c) features suggestive of choroidal detachment (dark colored dome-shaped elevations) OS

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The patient was referred to an oncologist, and meanwhile, magnetic resonance imaging (MRI) of the brain study was advised to look for optic nerve infiltration. The oncologist confirmed the diagnosis of CLL and started chemotherapy for the patient. During follow-up after 1 week, the patient showed dramatic symptomatic and clinical improvement in the right eye with minimal clinical improvement in the left eye. MRI of the brain showed bilateral SRD and CD with hyperintense supra-choroidal collection in the left eye and bilateral uninvolved optic nerves [Figure 4]a, [Figure 4]b, [Figure 4]c.
Figure 4: (a) T2-weighed axial magnetic resonance image showing serous retinal detachment on both sides (LE>RE), (b) T1-weighed transverse magnetic resonance image showing choroidal detachment OD, (c) T1-weighed transverse magnetic resonance image showing choroidal detachment OS with hyper-intense signals

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After 2 weeks of chemotherapy, there was complete regression of SRD and CD in the right eye with a best-corrected visual acuity of 6/18, and only partial regression of CD in the left eye with no improvement in vision [Figure 5]a and [Figure 5]b.
Figure 5: (a) Fundus picture OD showing regressed serous retinal detachment and choroidal detachment after 2 weeks of chemotherapy, (b) fundus picture OS showing regressed serous retinal detachment and partially regressed choroidal detachment after 2 weeks of chemotherapy

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  Discussion Top


The first patient had an undiagnosed intracranial space occupying lesion (ICSOL) that presented with visual symptoms. The most common differential diagnoses include primary or metastatic brain tumors, traumatic hematoma, parasitic lesions such as cysticercosis and hydatid cyst, inflammatory lesions such as bacterial abscess, tuberculoma, and fungal granulomas, and vascular lesions such as aneurysms.[1] Most of these lesions present with the triad of headache, vomiting, and papilledema due to raised intracranial tension (ICT) while some patients present with isolated visual symptoms.[2] Seizures and neurological deficit can also be encountered. In this patient, the ICSOL in the left parieto-occipital region would have caused a raise in ICT leading to the right-sided hemiparesis and ophthalmic manifestations.

The optic disc edema and retinal hemorrhages in case of raised ICT are proposed to be due to two reasons-mechanical causes such as compression of cavernous sinus, compression of central retinal vein, compression of optic nerve fibers, stasis in the capillaries of circle of Haller and Zinn, forcing of cerebrospinal fluid into optic nerve, or nonmechanical causes such as vasomotor and inflammatory and physicochemical disturbances.[3]

The visual disturbances due to raised ICT can be due to edema and ischemia of optic disc or compression of the optic tract by herniating brain tissue if any.[4] In this patient, there was a midline shift but no herniation of brain tissue was noted. The massive bilateral disc edema probably resulted in the gross diminution of vision in both the eyes.

Case 2

The second patient had a hidden hematological malignancy that presented with ocular features. Leukemia, especially the acute variety, is the most common hematological neoplasia to show ocular involvement, in the form of leukemic retinopathy, RD, and CD.[5],[6],[7] The ocular manifestations can be due to direct leukemic infiltration or due to indirect causes such as associated hematological abnormalities (anemia, thrombocytopenia, and hyperviscosity states), opportunistic infections, and complications related to therapy.[5]

B-scan ultrasonography, in this patient, did not show any evidence of leukemic infiltration in both the eyes. Hyperviscosity and stasis in choriocapillaris would have probably caused the RD and the disruption of trans-scleral outflow would have caused CD in the right eye.[8] However, in the left eye, we suspected a hemorrhagic CD due to the possible rupture of choriocapillaris. Although, clinically, the disc edema and peripapillary hemorrhages in the left eye suggested optic nerve infiltration,[9] there was no supportive radiological evidence for the same.


  Conclusion Top


In both cases, the visual symptoms urged the patients to seek medical attention. The attending ophthalmologist identified the primary pathology that lay elsewhere. The patients were then promptly referred to the concerned specialty departments for further management. The aim of this case report is to emphasize the fact that an ophthalmologist, with meticulous examination and strong eye of suspicion, can help in the diagnosis of remote pathologies.

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 Top

1.
Whiting AS, Johnson LN. Papilledema: Clinical clues and differential diagnosis. Am Fam Physician 1992;45:1125-34.  Back to cited text no. 1
    
2.
Pandit YK. Intracranial space occupying lesions. Indian J Ophthalmol 1965;13:1.  Back to cited text no. 2
  [Full text]  
3.
Hayreh SS. Pathogenesis of optic disc edema in raised intracranial pressure. Prog Retin Eye Res 2016;50:108-44.  Back to cited text no. 3
    
4.
Hayreh SS. Optic disc edema in raised intracranial pressure. VI. Associated visual disturbances and their pathogenesis. Arch Ophthalmol 1977;95:1566-79.  Back to cited text no. 4
    
5.
Dhaliwal RS, Schachat AP. Leukemias and lymphomas. In: Ryan SJ, editor. Retina: Basic Science and Inherited Retinal Diseases. 4th ed., Vol. 1. St. Louis: Elsevier Inc.; c2006. p. 851-65.  Back to cited text no. 5
    
6.
Kincaid MC, Green WR. Ocular and orbital involvement in leukemia. Surv Ophthalmol 1983;27:211-32.  Back to cited text no. 6
    
7.
Paydas S, Soylu MB, Disel U, Yavuz S, Sahin B, Ersoz C, et al. Serous retinal detachment in a case with chronic lymphocytic leukemia: No response to systemic and local treatment. Leuk Res 2003;27:557-9.  Back to cited text no. 7
    
8.
Mateo J, Ascaso FJ, Núñez E, Peiro C, González G, Cristóbal JA. Ophthalmological manifestations in acute lymphoblastic leukemia. InNovel Aspects in Acute Lymphoblastic Leukemia 2011 Nov 16. IntechOpen.  Back to cited text no. 8
    
9.
Volpe NJ. Compressive and infiltrative optic neuropathies. In: Miller NR, Newman NJ, editors. Walsh & Hoyt's Clinical Neuro-Ophthalmology. 6th ed., Vol. 1. Philadelphia: Lippincott Williams & Wilkins; c2005. p. 385-429.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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