Visual fields in metastatic choroidal carcinoma

British Journal of Ophthalmology, 1978, 62, 122-129

Visual fields in metastatic choroidal carcinomaRIRI SYLVIA MANOR, YUVAL YASSUR, ITZHAK BEN-SIRA, ANDROBERT BAR-ITZHACKFrom the Department of Ophthalmology, Beilinsoni Medical Center, Tel Aviv University Medical School,Petah Tikva, and Assaf Harofe Hospital, Tzrifin, Israel

SUMMARY A large choroidal metastasis was diagnosed in the right eye of a 44-year-old man referredfor admission to hospital because of 'retinal detachment.' At the same time in the second, symptom-less, eye a very small metastasis was observed. Close follow-up during the next month showed an

extremely rapid deterioration of visual acuity and visual field in this eye. This is thought to becharacteristic of such metastatic tumours in contrast to the slower progress of choroidal malignantmelanoma. The application of local radiotherapy to the same eye led to an impressive improvementin the visual acuity and visual field. The source of these bilateral choroidal metastases, which was

found only after the patient's death, proved to be a bronchial carcinoma.

The examination of visual fields in patients withmetastatic choroidal tumours is usually performedonly when symptoms become obvious.We hereby report a case of histologically proved

choroidal metastasis for two reasons: (1) thepresence of an advanced choroidal metastasis in oneeye as the earliest sign of bronchial carcinoma; and(2) the existence of a small, symptomless metastasisin the other eye; the growth of this metastasis andits subsequent regression after irradiation therapywere followed in static and kinetic studies of thevisual fields.

Case report

A 44-year-old man was referred to the ophthalmo-logical department of Beilinson Hospital with a2-month history of visual deterioration in the righteye. This had initially been diagnosed by his physi-cian as central serous chorioretinopathy and later asrhegmatogenous retinal detachment. On admissionthe patient appeared to be in good general health.Visual acuity was counting fingers at 20 cm in hisright eye and 6/6 in his left eye. Ocular movements,intraocular pressure, and refractive media werenormal in both eyes. In the right fundus there wasretinal and choroidal detachment in the form of3 high bullae almost touching each other near theoptic disc. There was shifting fluid in the third in-ferior bulla (Fig. 1). The detachment started at

Address for reprints: Dr R. S. Manor, Department ofOphthalmology, Beilinson Medical Center, Petah Tikva,Israiel

about 3 PD (disc diameters) posterior to the oraserrata, and there was no retinal tear to be seen.

In the left eye, 3 PD above the disc and slightlytemporal, there was an elevated, yellowish focus0-2 mm in width looking like a pigment epitheliumdetachment. Approximately 1-5 mm of the over-lying retina was shallowly detached (Fig. 2). Influorescein angiography there was a patchy filling of

Fig. 1 13 September 1975. The fundus of the right eyepresented 2 high bullae of retinal and choroidaldetachment which started a few PD from the ora serrataand almost touched each other near the optic disc. A thirdinferior bulging area presented shifting fluid

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Visual fields in metastatic chloroidal carcinoma

Fig. 2 13 September 1975. 1he fundus of the left eyefound to harbour in its nasal upper quadrant a verysmall, elevated, yellowish focus resembling a PEdetachment. Approximately I PD of the overlying retinawas shallowly detached

the tumour area with spots of hyperfluorescenceand hypofluorescence (Fig. 3). Kinetic visual fieldexamination of the left eye revealed a very densescotoma in the temporal inferior quadrant (Fig. 4).On static perimetry a depression of the field curveperipheral to the scotoma was also found corres-ponding to an area in the retina which seemed un-affected on fundus examination (Fig. 5).

In an attempt to discover the primary source ofthe bilateral choroidal metastases the patient wasthoroughly investigated. In the physical examina-tion an enlarged cervical lymph node and hepato-splenomegaly were found. A complete blood countand urine analysis were normal. There was anaccelerated erythrocyte sedimentation rate, anincreased level of glucose, and a reversed albumin-globulin ratio. The liver function tests gave ab-normal results. A liver scan showed an inhomo-geneous concentration of radioactive material inboth lobes. Brain and thyroid scans were normal.Radiographs of chest, skull, long bones, gastro-intestinal tract, and urinary system were all normal.

Biopsy of the enlarged cervical lymph noderevealed the presence of an undifferentiated ana-plastic carcinoma of unknown origin (Fig. 6). Thus

a bFig. 3 (a) Fluorescein of recirculation phase at 25 s: patchy filling of tumour area with spots of hyperflourescence andhypofluorescence. (b) Fluorescein of late phase at 5 min: patchy filling oftumour area persists; diffuse leakage,expressed by increased fluorescein staining, along with areas of hypofluorescence

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Riri Sylvia Manior, Ylival Yassiir, Itzhak Beli-Sira, ancd Robert Bar-ltzhack

the diagnosis of generalised carcinomatosis wasconfirmed, but there was no evidence of the primarysite.

Systemic anticarcinoma treatment was started bythe administration of 5-fluorouracil. Four weeksafter admission the patient's apparent good healthdeteriorated and jaundice appeared. There was alsoa rapid deterioration of visual acuity and the visualfield in the left eye. Thus visual acuity, which hadbeen 6/6 on 13 September, the day of admission,dropped to 6j10 with +2 0 spher. addition (acquired

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Fig. 4 13 September 1975. The ,visual field of the left 'good' eye, -

demonstrating the presence oJ avery dense scotoma in thetemporal inferior quadant

hypermetropia) on 10 October. The visual field,which was studied every few days by static andkinetic perimetry, also showed rapid progression ofthe scotoma (Figs. 7, 8). The fundal lesion of theleft eye expanded, extending to the macular area(Fig. 9). At this stage local radiotherapy (1,000 radsweekly for 3 weeks) was applied. One month afterbeginning this treatment visual acuity in the righteye improved to I m FC and in the left eye returnedto 5 6. There was also a dramatic regression in the leftfield scotoma as seen in kinetic and static perimetry

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Fig. 5 13 September 1975.Left eye: static perimetry(profile 225-75°) showingtemporally the sudden drop of thecurve at 22° and its gradualdescent from 50 to 30°. Thisdefect may be related to themetastatic tumour, which gave anabsolute scotoma and to thesurrounding detachment, whichgave a relative, gradualdepression of acuity cuirve

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Visualfields in metastatic choroiclalcarcinoma1

(Figs. 10, II). At the same time the ophthalmos-copic picture showed a regression of the exudativeretinal detachments in both eyes. However, after 2months in hospital and just 2 days after the abovevisual field examination, the patient died of genera-lised carcinomatosis.

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Fig. 6 Cervical lymph node biopsy. The lymph nodetissue was replaced by tunmour tissue comtiposed of sniallhlyperchrolnutic nuclei with s(anty cytoplasm. H and E

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PATHOLOGICAL FINDINGSThe primary tumour was found to be undifferen-tiated bronchical carcinoma, small-cell type, locatedin the apex of the right lung (Fig. 12). There werewidespread metastases in the liver, adrenal glands,pleura, stomach, kidneys, thyroid, paratracheal andparapancreatic lymph nodes, leptomeninges, andhypophysis. Bile stasis in the liver and acute pan-creatitis were also found.

GROSS AND MICROSCOPICOCULAR EXAMINATIONThe eyes were carefully studied with a clinico-pathological correlation in view. In the right eye abrownish mass was observed under the retina at theposterior pole. In the left eye a 3 mm brownishtumour was found under the retina at the uppernasal quadrant slightly above the optic disc (Fig. 13).The histological examination of the right eye

showed the tumoral mass to be composed of ex-tremely anaplastic cells with hyperchromatic nucleiand scanty cytoplasm arranged mainly round choroi-dal vessels (Fig. 14). Numerous necrotic cells andempty areas were present owing to destruction ofcells (Fig. 15). Choroidal vessels showed thickeningof the walls, and some of them were obstructed. Theretinal pigment epithelium was seen to have reactedeither by hyperplasia or by drusen formation. Thesubretinal fluid was coagulated.

Histological examination of the tumour in theleft eye showed the same cellular characteristicsdescribed above. At the site of the tumour there was

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Fig. 8 10 October 1975. Staticperimetry of 225-75° showingthe presence ofa central scotomaand complete deterioration of thetemporal field

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chorioretinal adhesion and round it a flat retinaldetachment (Fig. 16).

Discussion

Metastatic carcinoma of the eye has been found tobe bilateral in 4.4% to 30% of all such cases inreported series (Albert et al., 1967; Bloch andGartner, 1971; Casanovas, 1906; Cordes, 1944;Duke-Elder and Perkins 1966; Ferry and Font,

Fig. 9 10 October 197). lThe drawing of the leJt fundusshows the rapid extension of the initially very small

metastatic tumour

1974; Franqois et al., 1976; Haye and Calle, 1972;Yaeger et al., 1971). Recently a number of newcases of bilateral choroidal metastases have beenreported (Asayama et al., 1974; Fu et al., 1974;Walker, 1974). Reese (1963), on the other hand,pointed out that simultaneous bilateral involve-ment appears very seldom. However, it is possiblefor a small metastasis in the second eye to be over-looked. Therefore it may be of value, when possible,to perform a careful bilateral visual field examina-tion in such patients to detect early signs of metas-tasis, i.e., the presence of scotomas. Furthermore,successive visual field studies, in addition to otherophthalmological examinations, may be helpful inmaking the differential diagnosis between rnetas-tatic carcinoma and malignant melanoma. As iswell known, even the fluorescein angiographypattern of choroidal metastasis is often indistin-guishable from that seen in choroidal melanomasand haemangiomas (Davis and Robertson, 1973).With malignant melanoma the rate of growth of thetumour and the visual field progression are usuallyslower (Hogeweg et al., 1976). The accurate dif-ferential diagnosis may serve to avoid unnecessaryenucleation in metastatic carcinoma. Furthermore,when the eye symptoins are the presenting signs ofcarcinomatosis, the correct diagnosis will lead tothe proper approach, including a general check-up.The rapid deterioration in visual acuity and visual

fields in choroidal metastasis is exemplified by ourcase also. During the period of I month the weeklyexaminations showed an impressive change invisual fields which was paralleled by an obviousextension of the choroidal metastases.The beneficial effect of irradiation treatment on

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choroidal metastatic lesions has been amply docu-mented (Gillet, 1971; Casanovas, 1966; Haye andCalle, 1972; MacMichael, 1969; Reese, 1963;Walker, 1974; Yaeger et al., 1971). In our case alsothe regression of the fundal lesion after irradiationtherapy was reflected in the improvement of visualacuity and visual fields.Another point of interest in this case is the fact

that the intraocular metastases were the first sign ofgeneralised carcinomatosis. Also worth noting is the

Fig. 10 19 November 1975. Thevisual field of the left eye, - 6Sshowing a dranmatic regression ofthe scotoma involving the temporal \ \lower quadrant after localradiotherapy

fact that the source of metastatic embolisation wasnot found before death. Ferry and Font (1974)found that the most common cause of ocularmetastasis was breast carcinoma but that, when theocular metastasis was the presenting sign, the com-monest source of it was bronchial carcinoma. Incases in which the primary tumour cannot be identi-fied during life this statistically valuable finding maybe helpful in predicting the site of the primarytumour.

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Fig. 11 19 Nove:mber 1975.Left eye: static perimetry showedthe reappearance oJ the tempporallower field curve after localradiotherapy

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Fig.i,12 i

showing tumour mass composed of anaplastic small cells f_bb=arising in bronchial mucosa and penetrating into lung __I _ _parenchyma. H anzd E x 120) ;

Fig. 14 (right) Tumoral cells in the choroid of the right Q<eye. These were very anaplastic cells with hyperchromatic Jnuclei and scanty cytoplasm arranged mostly around,_choroidal vessels. (H and E x 440) a

8Lt* ; i} t '\ E 5~~~~~~Fig. 13 Left: the horizontal\E.} f j ,1 | f ~~~~~~~~~~~sectionof the right eye. TumourV8Si*M.\ Ee/ }: .' ~~~~~~~~~~massoccupies the posterior polei;>{ \ \ > \ ~~~~~~~~~~~ofthe eye, detaching the retinatwt,w,st ss t j ~~~~~~~~~~~~~Right:the oblique section of lefta_ ^w \N if ~~~~~~~~~~~~eye (upper temporal-lower nasal;e,J tX plane), tumour mass detaching-,k A __ ~~~~~~~~~~~~theretina

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Fig. 15 Numerous necrotic cells and empty areas due todestruction of cells were evident in this preparation of theright eye. (H and E x 160)

References

Albert, D. M., Rubinstein, R. A., and Scheie, H. G. (1967).Tumor metastasis to the eye. 1. Incidence in 213 adultpatients with generalized malignancy. American Journtalof Ophthalmology, 63, 723-733.

Asayama, K., Uyama, M., and Nabeshima, Y. (1974). Acase of metastatic carcinoma of the choroid simulatingmalignant choroidal melanoma. Folia OphthalmologicaJaponica, 25, 1306-1312.

Bloch, R. S., and Gartner, S. (1971). The incidence of ocularmetastatic carcinoma. Archives of Ophthalmology, 85,673-675.

Casanovas, J. (1966). Tumeurs metastatiques de l'oeil et del'orbite. Ophthalnologica, 151, 272-283.

Cordes, F. C. (1944). Bilateral metastatic carcinoma of thechoroid with x-ray therapy to one eye. American Journalof Ophthalmology, 27, 1355-1370.

Davis, D. L., and Robertson, D. M. (1973). Fluoresceinangiography of metastatic choroidal tumors. Archives ofOphthalmology, 89, 97-99.

Duke-Elder, S., and Perkins, E. S. (1966). System of Ophthal-mology, Vol. 8, p. 917. Henry Kimpton: London.

Ferry, A. P., and Font, R. L. (1974). Carcinoma metastaticto the eye and orbit. 1. A clinico-pathologic study of 227cases. Archives of Ophthalmology, 92, 276-286.

Franqois, J., Hanssens, H., and Verbraeken, H. (1976).Intraocular metastasis as first sign of generalized carcino-matosis. Annals of Ophthalmology, 8, 405-419.

Fig. 16 The tumour of the left eye showed the samecellular characteristics. A flat retinal detachment isobserved round the tumour. (H and E x 120)

Fu, Y. S., McWilliams, N. B., Stratford, T. P., and Kay, S.(1974). Bronchial carcinoid with choroidal metastasis inan adolescent. Cancer, 33, 707-715.

Gillet, R. B. (1971). Metastatic carcinoma of the choroid.Te ras Medicine, 67, 72-75.

Haye, C., and Calle, R. (1972). Tumeurs metastatiqucschoroidiennes. Annales D'Oculistique, 205, 549-555.

Hogeweg, M., Bos, P. J. M., Greve, E. L., and De Haan,A. B. (1976). Malignant melanomas of the choroid thaton fluorescein angiography and perimetry gave theimpression of naevi. Documentt Ophthalmologica, 40,301-318.

MacMichael, I. M. (1969). Management of choroidalmetastases from breast carcinoma. British Journial ofOphthalmology, 53, 782-785.

Reese, A. B. (1963). Tumors of the eye. 2nd edn., p. 514.Paul B. Hoeber: New York.

Walker, C. (1974). Bilateral choroidal metastases from'adenoma' of the bronchus. British Joutrnal of Ophthal-mniology, 58, 625-629.

Yaeger, E. A., Frayer, W. C., Southard, M. E., et al. (1971).Effect of radiation therapy on metastatic choroidaltumors. Transactions of the American Academy ofOphthalmology and Otolaryngology, 75, 94-101.

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