Case Report Choroidal Metastasis secondary to Lung Malignancy

Background: Ocular malignancies are uncommon and often occur as secondary metastases. Due to the rarity of developing ocular metastases, special attention should be placed on history gathering and physical examination of a patient presenting with painless vision loss. Metastases are commonly observed in the posterior pole due to the rich microvasculature. Secondary metastases show a smoother morphology whereas primary ocular metastases may have a shaggy appearance. External beam radiation therapy, the most available treatment modality, is the conventional method for treating choroidal metastases due to preservation of vision and low occurrence of acute complications. Stereotactic radiosurgery, brachytherapy plaque insertion, and proton beam therapy are less common alternatives to external radiation treatment due to limited research and availability. Case Presentation: A 62-year-old Caucasian male with recently diagnosed primary lung adenocarcinoma 2 months prior was referred by his primary care physician and oncologist for ophthalmic evaluation before initiation of chemotherapy. The patient presented with a chief complaint of sudden, painless vision loss in the right eye. His symptoms started two weeks prior and had remained constant since onset. The patient reported that he had difficulty with both far and near vision. He denied recent fever or illness, trauma, severe or unusual headaches, double vision, jaw pain, scalp tenderness, or neurological impairment (e.g., dizziness, numbness, and tingling). The patient reported no improvement in vision with his bifocal lenses. Other medical history included prostate cancer status post resection followed by radiation, chronic obstructive pulmonary disease, polysubstance abuse, and ongoing tobacco use. The patient's ocular history included previous traumatic injury to his left eye during childhood, which resulted in a total retinal detachment and subsequent vision loss. Family medical and ocular histories were unremarkable. Snellen visual acuity was best corrected to 20/250 in his right eye. Best-corrected visual acuity in his left eye was counting fingers at 3 feet, secondary to his traumatic injury. His extraocular motilities were full and he denied pain or diplopia with gaze change. Pupil examination revealed sluggish responses in both the right and left pupils. Goldmann tonometry revealed intraocular pressures of 12mmHg in the right eye and 18mmHg in the left eye. Slit lamp examination was unremarkable in both eyes. Dilated fundus examination revealed an elevated, smooth yellow-white lesion superior to the macula and significant vascular tortuosity in the right eye. The left eye revealed mild tortuosity, and diffuse scarring secondary to a longstanding retinal detachment. Optical coherence tomography (OCT) imaging was performed over the retinal lesion in the right eye and revealed significant subretinal fluid (Figure 2). The assessment at this time was bilateral hypertensive retinopathy and presumed malignant neoplasm of the right choroid consistent with metastatic lung cancer. The patient was referred to a retinal specialist for additional testing and treatment the same day. External beam radiation therapy was offered for palliation but rapid disease progression hindered treatment. Conclusion: This case highlights a rare complication of malignancy, emphasizing the importance of comprehensive history gathering and physical examination.