Clinical Review & Education
JAMA Ophthalmology Clinical Challenge
Serous Macular Detachment Following a Systemic Corticosteroid Injection Christina Y. Weng, MD, MBA; J. William Harbour, MD
A
C
B
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D
H E
F
200 µm
Figure. Fundus photograph (A-B) of the right eye demonstrates a serous macular detachment with yellowish choroidal discoloration. A, Similar yellowish choroidal lesions (arrowheads) were present in the nasal and inferior midperiphery. B, The enlarged image demonstrates the extent of serous macular detachment (arrowheads). C, Wide-angle fluorescein angiography in the late venous phase of the right eye shows an area between the disc and fovea with scattered hyperfluorescent hotspots. Magnified views of the macular lesion (D), nasal lesion (E), and inferior lesion (F). G, B-scan ultrasonography of the right eye shows a subtle nonspecific choroidal thickening with medium internal reflectivity. The arrowhead points to the choroidal infiltration by the metastatic tumor. H, Spectral-domain optical coherence tomography of the right eye demonstrates serous macular detachment with localized subtle choroidal vascular attenuation, infiltration, and thickening (arrowheads).
A 38-year-old woman developed acute painless blurred vision in her right eye 3 weeks after receiving a single injection of corticosteroid in her deltoid for stenosing tenosynovitis. Her medical history was significant for stage II breast carcinoma with positive lymph nodes, which was diagnosed and treated 5 years prior. Subsequent annual metastatic surveillance test results had been negative for recurrence. Visual acuity was 20/60 OD and 20/20 OS. Ophthalmoscopy of the right eye revealed a 6 × 6-mm circumscribed serous macular detachment with turbid subretinal fluid. Similar lesions were present in the nasal and inferior midperiphery (Figure, A and B). The left eye was unremarkable. Fluorescein angiography (FA) showed hyperfluorescent pinpoint hot spots with interspersed hypofluorescent patches in the areas of the lesions (Figure, C-F). Notably absent on FA Quiz at were retinal pigment epithelium (RPE) leakage, a jamaophthalmology.com smokestack pattern of subretinal leakage, or RPE gutter defects. B-scan ultrasonography demonstrated choroidal thickening nasal to the optic disc (Figure, G); vascularity could not be assessed. Optical coherence tomography (OCT) showed a localized serous macular detachment with a focal area of choriocapillaris infiltration and thickening near the nasal edge of the detachment (Figure, H).
jamaophthalmology.com
WHAT WOULD YOU DO NEXT?
A. Consider managing as multifocal central serous chorioretinopathy B. Consider a diagnosis of choroidal metastasis C. Obtain workup for Vogt-KoyanagiHarada syndrome D. Blood tests to consider diagnosis of syphilitic chorioretinitis
(Reprinted) JAMA Ophthalmology April 2015 Volume 133, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/02/2015
473
Clinical Review & Education JAMA Ophthalmology Clinical Challenge
Diagnosis A diagnosis of metastatic breast cancer was suspected and a systemic workup was obtained. A bone scan revealed multiple active foci within the ribs and brain magnetic resonance imaging revealed an 8 × 4-mm dural-based enhancing lesion at the superior falx, consistent with metastasis.
What To Do Next B. Consider a diagnosis of choroidal metastasis
Discussion Breast cancer is the most common primary site of choroidal metastasis in women.1 Choroidal metastasis from breast cancer typically presents as a creamy yellow choroidal mass with overlying serous retinal detachment most commonly occurring in the posterior pole.2 The lesions are often multiple and bilateral. Ultrasonography typically shows an elevated choroidal mass with medium-high irregular internal reflectivity and minimal vascularity. Fluorescein angiography often shows patchy late hyperfluorescence with pinpoint leakage. In contrast, the FA appearance of central serous chorioretinopathy (CSCR) typically reveals 1 or more pinpoint areas of leakage at the level of the RPE (often in a smokestack or expansile dot pattern of dye leakage in the subretinal space) and geographic areas of chronic RPE mottling. These findings are occasionally accompanied by linear tracks or gutters of RPE alteration at sites of previous subretinal fluid.3 In both choroidal metastasis and CSCR, the OCT may show serous retinal detachment but these entities differ in the appearance of the choroid. Central serous chorioretinopathy is often associated with marked thickening of the choroid due to enlargement of choroidal vessels.4 In contrast, here choroidal metastasis appeared on the OCT as a thickening of the choroid owing to infiltration and attenuation of choroidal vessels by solid tissue. Opti-
cal coherence tomography was very helpful in this patient by showing the subtle choroidal mass that was not detectable on clinical examination and nondiagnostic on ultrasonography. Patients with suspected choroidal metastasis should undergo metastatic workup, which may include magnetic resonance imaging of the brain, computed tomography of the chest/abdomen/pelvis, a bone scan, a positron emission tomographic scan, and serum cancer markers. If the metastatic workup result is negative and there remains a strong suspicion for choroidal metastasis, a fine-needle aspiration biopsy can often establish the diagnosis. Treatment options for choroidal metastasis include systemic chemotherapy, external beam radiation therapy, laser photocoagulation, photodynamic therapy, transpupillary thermotherapy, and observation. Systemic chemotherapy was used in this patient owing to systemic involvement and external beam radiation therapy was recommended owing to macular involvement and visual impairment.5 Metastasis of systemic cancer to the choroid can present with a wide range of clinical findings. Features of this case that initially suggested a diagnosis of CSCR included the serous retinal detachments, lack of obvious choroidal mass, history of corticosteroid use, and geographic areas of RPE mottling on FA. The features that favored a choroidal metastasis diagnosis included the yellowish color, choroidal infiltration on OCT, lack of FA findings typical of CSCR, and history of breast cancer. This case highlights the value of OCT in such cases and emphasizes the importance of obtaining a detailed history in patients with suspected CSCR in whom the clinical features are atypical.
Patient Outcome Systemic therapy was instituted with intravenous bevacizumab, paclitaxel, and denosumab along with 12 fractions (25 Gy) of external beam radiotherapy to the right eye. At 14 weeks after completion of external beam radiation therapy, visual acuity returned to 20/25 OD and has remained stable through 1 year of follow-up with no radiation retinopathy or cataract.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Ocular Oncology Service, Bascom Palmer Eye Institute and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
1. Freedman MI, Folk JC. Metastatic tumors to the eye and orbit: patient survival and clinical characteristics. Arch Ophthalmol. 1987;105(9):1215-1219.
Corresponding Author: Christina Y. Weng, MD, MBA, Ocular Oncology Service, Bascom Palmer Eye Institute and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 900 NW 17th St, Miami, FL 33136 ([email protected]).
2. Demirci H, Shields CL, Chao AN, Shields JA. Uveal metastasis from breast cancer in 264 patients. Am J Ophthalmol. 2003;136(2):264-271. 3. Nicholson B, Noble J, Forooghian F, Meyerle C. Central serous chorioretinopathy: update on pathophysiology and treatment. Surv Ophthalmol. 2013;58(2):103-126.
4. Imamura Y, Fujiwara T, Margolis R, Spaide RF. Enhanced depth imaging optical coherence tomography of the choroid in central serous chorioretinopathy. Retina. 2009;29(10):1469-1473. 5. Rudoler SB, Shields CL, Corn BW, et al. Functional vision is improved in the majority of patients treated with external-beam radiotherapy for choroid metastases: a multivariate analysis of 188 patients. J Clin Oncol. 1997;15(3):1244-1251.
Conflict of Interest Disclosures: None reported.
474
JAMA Ophthalmology April 2015 Volume 133, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/02/2015
jamaophthalmology.com
JAMA Ophthalmology Clinical Challenge
Serous Macular Detachment Following a Systemic Corticosteroid Injection Christina Y. Weng, MD, MBA; J. William Harbour, MD
A
C
B
G
D
H E
F
200 µm
Figure. Fundus photograph (A-B) of the right eye demonstrates a serous macular detachment with yellowish choroidal discoloration. A, Similar yellowish choroidal lesions (arrowheads) were present in the nasal and inferior midperiphery. B, The enlarged image demonstrates the extent of serous macular detachment (arrowheads). C, Wide-angle fluorescein angiography in the late venous phase of the right eye shows an area between the disc and fovea with scattered hyperfluorescent hotspots. Magnified views of the macular lesion (D), nasal lesion (E), and inferior lesion (F). G, B-scan ultrasonography of the right eye shows a subtle nonspecific choroidal thickening with medium internal reflectivity. The arrowhead points to the choroidal infiltration by the metastatic tumor. H, Spectral-domain optical coherence tomography of the right eye demonstrates serous macular detachment with localized subtle choroidal vascular attenuation, infiltration, and thickening (arrowheads).
A 38-year-old woman developed acute painless blurred vision in her right eye 3 weeks after receiving a single injection of corticosteroid in her deltoid for stenosing tenosynovitis. Her medical history was significant for stage II breast carcinoma with positive lymph nodes, which was diagnosed and treated 5 years prior. Subsequent annual metastatic surveillance test results had been negative for recurrence. Visual acuity was 20/60 OD and 20/20 OS. Ophthalmoscopy of the right eye revealed a 6 × 6-mm circumscribed serous macular detachment with turbid subretinal fluid. Similar lesions were present in the nasal and inferior midperiphery (Figure, A and B). The left eye was unremarkable. Fluorescein angiography (FA) showed hyperfluorescent pinpoint hot spots with interspersed hypofluorescent patches in the areas of the lesions (Figure, C-F). Notably absent on FA Quiz at were retinal pigment epithelium (RPE) leakage, a jamaophthalmology.com smokestack pattern of subretinal leakage, or RPE gutter defects. B-scan ultrasonography demonstrated choroidal thickening nasal to the optic disc (Figure, G); vascularity could not be assessed. Optical coherence tomography (OCT) showed a localized serous macular detachment with a focal area of choriocapillaris infiltration and thickening near the nasal edge of the detachment (Figure, H).
jamaophthalmology.com
WHAT WOULD YOU DO NEXT?
A. Consider managing as multifocal central serous chorioretinopathy B. Consider a diagnosis of choroidal metastasis C. Obtain workup for Vogt-KoyanagiHarada syndrome D. Blood tests to consider diagnosis of syphilitic chorioretinitis
(Reprinted) JAMA Ophthalmology April 2015 Volume 133, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/02/2015
473
Clinical Review & Education JAMA Ophthalmology Clinical Challenge
Diagnosis A diagnosis of metastatic breast cancer was suspected and a systemic workup was obtained. A bone scan revealed multiple active foci within the ribs and brain magnetic resonance imaging revealed an 8 × 4-mm dural-based enhancing lesion at the superior falx, consistent with metastasis.
What To Do Next B. Consider a diagnosis of choroidal metastasis
Discussion Breast cancer is the most common primary site of choroidal metastasis in women.1 Choroidal metastasis from breast cancer typically presents as a creamy yellow choroidal mass with overlying serous retinal detachment most commonly occurring in the posterior pole.2 The lesions are often multiple and bilateral. Ultrasonography typically shows an elevated choroidal mass with medium-high irregular internal reflectivity and minimal vascularity. Fluorescein angiography often shows patchy late hyperfluorescence with pinpoint leakage. In contrast, the FA appearance of central serous chorioretinopathy (CSCR) typically reveals 1 or more pinpoint areas of leakage at the level of the RPE (often in a smokestack or expansile dot pattern of dye leakage in the subretinal space) and geographic areas of chronic RPE mottling. These findings are occasionally accompanied by linear tracks or gutters of RPE alteration at sites of previous subretinal fluid.3 In both choroidal metastasis and CSCR, the OCT may show serous retinal detachment but these entities differ in the appearance of the choroid. Central serous chorioretinopathy is often associated with marked thickening of the choroid due to enlargement of choroidal vessels.4 In contrast, here choroidal metastasis appeared on the OCT as a thickening of the choroid owing to infiltration and attenuation of choroidal vessels by solid tissue. Opti-
cal coherence tomography was very helpful in this patient by showing the subtle choroidal mass that was not detectable on clinical examination and nondiagnostic on ultrasonography. Patients with suspected choroidal metastasis should undergo metastatic workup, which may include magnetic resonance imaging of the brain, computed tomography of the chest/abdomen/pelvis, a bone scan, a positron emission tomographic scan, and serum cancer markers. If the metastatic workup result is negative and there remains a strong suspicion for choroidal metastasis, a fine-needle aspiration biopsy can often establish the diagnosis. Treatment options for choroidal metastasis include systemic chemotherapy, external beam radiation therapy, laser photocoagulation, photodynamic therapy, transpupillary thermotherapy, and observation. Systemic chemotherapy was used in this patient owing to systemic involvement and external beam radiation therapy was recommended owing to macular involvement and visual impairment.5 Metastasis of systemic cancer to the choroid can present with a wide range of clinical findings. Features of this case that initially suggested a diagnosis of CSCR included the serous retinal detachments, lack of obvious choroidal mass, history of corticosteroid use, and geographic areas of RPE mottling on FA. The features that favored a choroidal metastasis diagnosis included the yellowish color, choroidal infiltration on OCT, lack of FA findings typical of CSCR, and history of breast cancer. This case highlights the value of OCT in such cases and emphasizes the importance of obtaining a detailed history in patients with suspected CSCR in whom the clinical features are atypical.
Patient Outcome Systemic therapy was instituted with intravenous bevacizumab, paclitaxel, and denosumab along with 12 fractions (25 Gy) of external beam radiotherapy to the right eye. At 14 weeks after completion of external beam radiation therapy, visual acuity returned to 20/25 OD and has remained stable through 1 year of follow-up with no radiation retinopathy or cataract.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Ocular Oncology Service, Bascom Palmer Eye Institute and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
1. Freedman MI, Folk JC. Metastatic tumors to the eye and orbit: patient survival and clinical characteristics. Arch Ophthalmol. 1987;105(9):1215-1219.
Corresponding Author: Christina Y. Weng, MD, MBA, Ocular Oncology Service, Bascom Palmer Eye Institute and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 900 NW 17th St, Miami, FL 33136 ([email protected]).
2. Demirci H, Shields CL, Chao AN, Shields JA. Uveal metastasis from breast cancer in 264 patients. Am J Ophthalmol. 2003;136(2):264-271. 3. Nicholson B, Noble J, Forooghian F, Meyerle C. Central serous chorioretinopathy: update on pathophysiology and treatment. Surv Ophthalmol. 2013;58(2):103-126.
4. Imamura Y, Fujiwara T, Margolis R, Spaide RF. Enhanced depth imaging optical coherence tomography of the choroid in central serous chorioretinopathy. Retina. 2009;29(10):1469-1473. 5. Rudoler SB, Shields CL, Corn BW, et al. Functional vision is improved in the majority of patients treated with external-beam radiotherapy for choroid metastases: a multivariate analysis of 188 patients. J Clin Oncol. 1997;15(3):1244-1251.
Conflict of Interest Disclosures: None reported.
474
JAMA Ophthalmology April 2015 Volume 133, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/02/2015
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