Cancer-associated nummular loss of the pigment epithelium

CHOROIDEREMIA: Retinal Degeneration With an Unmet Need

PURPOSE

Choroideremia is an incurable, X-linked, recessive retinal dystrophy caused by loss of function mutations in the CHM gene. It is estimated to affect approximately 1 in 50,000 male patients. It is characterized by progressive degeneration of the retinal pigment epithelium, choroid, and photoreceptors, resulting in visual impairment and blindness. There is an unmet need in choroideremia, because currently, there are no approved treatments available for patients with the disease.

METHODS

We review the patient journey, societal impact, and emerging treatments for patients with choroideremia.

RESULTS

Its relative rarity and similarities with other retinal diseases in early years mean that diagnosis of choroideremia can often be delayed. Furthermore, its impact on affected individuals, and wider society, is also likely underestimated. AAV2-mediated gene therapy is an investigational treatment that aims to replace the faulty CHM gene. Early-phase studies reported potentially important visual acuity gains and maintenance of vision in some patients, and a large Phase 3 program is now underway.

CONCLUSION

Choroideremia is a disease with a significant unmet need. Interventions that can treat progression of the disease and improve visual and functional outcomes have the potential to reduce health care costs and enhance patient quality of life.

UNILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION

PURPOSE

To report a unilateral case of what is named bilateral diffuse uveal melanocytic proliferation and consider the consequences of this finding.

METHODS

The ocular findings were investigated with multimodal imaging to include color fundus photography, fluorescein angiography, autofluorescence imaging, and enhanced depth imaging optical coherence tomography.

RESULTS

A 66-year-old woman had a history of breast cancer 23 years previously that was treated and the patient was free of disease since. She developed a recent decrease in visual acuity in her left eye prompting referral. She was seen to have an alteration in the pigmentation of the posterior pole of the left eye with dispersed red placoid spots. Autofluorescence imaging showed nummular areas of absent autofluorescence signal, which corresponded to areas of hyperfluorescence during fluorescein angiography. The placoid spots were hyperautofluorescent and hypofluorescent in autofluorescence and fluorescein angiography, respectively. She had diffuse thickening and infiltration of the choroid in the left eye. Because of the ocular findings, the patient underwent a systemic evaluation and was found to have widely metastatic disease with an unknown primary cancer. No progression of disease was seen in the left eye over a 6-month follow-up, and the right eye never showed any abnormality, except for a modest cataract, by any means of examination.

CONCLUSION

Bilateral uveal melanocytic proliferation has been attributed to a paraneoplastic process, allegedly from a factor in the IgG fraction of the serum. However, unilateral involvement suggests that there are other factors involved in disease manifestation.

Multimodal imaging of bilateral diffuse uveal melanocytic proliferation associated with an iris mass lesion

Background

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a rare, paraneoplastic syndrome characterized by bilateral painless visual loss and proliferation of choroidal melanocytes in association with an underlying systemic malignancy. We report a case of bilateral diffuse uveal melanocytic proliferation associated with an underlying gynecological malignancy that also features the infrequent finding of an iris mass lesion, using multimodal imaging including ultra-widefield imaging, spectral domain and swept-source optical coherence tomography.

Case presentation

A 59-year-old white female with a prior history of gynecological malignancy in remission presented with progressive bilateral visual loss over several weeks. The patient was noted to have a focal iris mass lesion in her right eye. Ultra-widefield color fundus photography showed a characteristic bilateral ‘giraffe pattern’ of pigmentary changes extending into the periphery as well as multiple discrete deeply pigmented lesions. Ultra-widefield autofluorescence was useful for visualizing the full extent of involvement. Indocyanine green angiography helped to demarcate the discrete pigmented choroidal lesions. Swept-source OCT clearly delineated the alternating zones of retinal pigment epithelium (RPE) thickening and RPE loss, as well as the prominent choroidal infiltration and thickening.

Conclusions

BDUMP is an important diagnosis to consider in the presence of multiple discrete melanocytic choroidal lesions, diffuse choroidal thickening, characteristic RPE changes, iris mass lesions and exudative retinal detachment. Ultra-widefield imaging may demonstrate more extensive lesions than that detected on clinical examination or standard field imaging. Imaging with SS-OCT shows choroidal and RPE characteristics that correlate well with known histopathology of this entity.

NEAR-INFRARED AUTOFLUORESCENCE IN BILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION ASSOCIATED WITH ESOPHAGEAL CARCINOMA AND CHOROIDAL METASTASIS

PURPOSE

To investigate the advantage of near-infrared autofluorescence (787 nm) for the detection of melanocytic lesions in a patient with bilateral diffuse uveal melanocytic proliferation in association with esophageal carcinoma complicated by most likely unilateral choroidal metastasis.

METHODS

In this retrospective case report, a 55-year-old woman referred for the evaluation of sudden visual loss underwent normal ophthalmological evaluation and, in addition, was examined with near-infrared reflectance, near-infrared autofluorescence, fundus autofluorescence (Heidelberg Retina Angiograph II [HRA2; Heidelberg Engineering]), spectral domain optical coherence tomography (Spectralis OCT; Heidelberg Engineering), and multifocal electroretinography (RetiScan; Roland Consult).

RESULTS

The patient had been diagnosed with esophageal carcinoma 3 months before the onset of visual symptoms. The visual acuity was 20/40 in the right eye and 20/20 in the left eye. Bilateral patchy melanocytic proliferation was detected on ophthalmoscopy. The extent of lesions was best detected with near-infrared reflectance and near-infrared autofluorescence, whereas fundus autofluorescence and spectral domain optical coherence tomography did not reveal alterations of the outer retina or retinal pigment epithelium in this early stage of bilateral diffuse uveal melanocytic proliferation. The right eye showed in addition to the findings on the left eye choroidal folds in the fovea and an elevated lesion inferotemporal of the fovea suspicious of a choroidal metastasis. In the B-scan ultrasonography, a homogenous lesion was seen. Spectral domain optical coherence tomography demonstrated a mild accumulation of subretinal fluid adjacent to and over the choroidal metastasis. Transretinal biopsy of this elevated lesion revealed a low differentiated carcinoma of squamous epithelium, compatible with choroidal metastasis of the esophageal carcinoma. The choroidal metastasis increased within 3 months after the first visit. The visual acuity dropped in both eyes. The patient died 6 months after her first visit.

CONCLUSIONS

Bilateral diffuse uveal melanocytic proliferation can be associated with esophageal carcinoma as a systemic malignancy. Near-infrared imaging can be helpful to detect early stages of BDUMP and can help offer recently reported treatment options at an early stage of disease.

Bilateral diffuse uveal melanocytic proliferation associated with renal cell carcinoma

PURPOSE

To report a case of bilateral diffuse uveal melanocytic proliferation associated with an asymptomatic renal cell carcinoma.

DESIGN

Clinical case report.

METHODS

A 70-year-old man presented with a 7-month history of bilateral visual loss. Ophthalmoscopic examination, fluorescein angiography, ocular coherence tomography, and a search for underlying systemic malignancy were performed.

RESULTS

Examination revealed multiple melanocytic uveal proliferations in both eyes. Fluorescein angiography revealed a pattern of multiple areas of early hyperfluorescence, and ocular coherence tomography showed serous detachment of the central retina. Abdominal computerized tomography scans showed a large tumor in the left kidney and nodular involvement in the right kidney. Pathologic examination revealed a clear cell carcinoma of the kidney.

CONCLUSION

A literature review revealed a total of 40 cases of bilateral diffuse uveal melanocytic proliferation. To our knowledge, this is the first case to be associated with renal cell carcinoma.

Bilateral diffuse uveal melanocytic proliferation presenting as small choroidal melanoma

Purpose. To describe a patient with Bilateral Diffuse Uveal Proliferation who presented initially with a clinical picture consistent with choroidal melanoma. Methods. Presentation of a clinical case with fundus photos, fluorescein angiography, and optical coherence tomography. Results. A 70-year-old Caucasian male with history of esophageal cancer presented with an asymptomatic pigmented choroidal lesion in his left eye initially diagnosed as choroidal nevus. This lesion enlarged over the course of a year and developed orange pigment and increased thickness. A metastatic workup was negative, and a radioactive iodine plaque was placed on the left eye. Over the next six months, the visual acuity in his left eye decreased. His clinical picture was consistent with unilateral Diffuse Uveal Proliferation. A recurrence of his esophageal carcinoma with metastasis was discovered and palliative chemotherapy was initiated. Although his visual acuity improved in the left eye, similar pigmentary changes developed in the right fundus. His visual acuity in both eyes gradually decreased to 20/200 until his death a year later. Conclusion. BDUMP should always be considered in the differential diagnosis of patients with pigmented fundus lesions and a history of nonocular tumors.

Cancer-associated nummular loss of RPE: expanding the clinical spectrum of bilateral diffuse uveal melanocytic proliferation

This report describes a case of cancer-associated nummular retinal pigment epithelium loss associated with uterine cancer. The patient had progressive visual loss despite treatment with plasmapheresis, intravenous immunoglobulin, and local injection of corticosteroids. Clinical deterioration was corroborated by extension of the areas of retinal pigment epithelium loss, progression of cataracts, and growth of pigmented choroidal and iris lesions. Previously published cases of cancer-associated nummular retinal pigment epithelium loss did not describe the presence of cataracts or uveal melanocytic lesions. This case expands the clinical spectrum of bilateral diffuse uveal melanocytic proliferation.

High-resolution OCT imaging of RPE degeneration in bilateral diffuse uveal melanocytic proliferation

Bilateral diffuse uveal melanocytic proliferation is a rare paraneoplastic syndrome that presents with bilateral progressive loss of vision. A 70-year-old woman presented with a 3-month history of progressive, bilateral vision loss. The patient had bilateral, diffuse, shallow, subretinal fluid with patchy, reddish-brown lesions at the level of the retinal pigment epithelium (RPE) that showed significant early hyperfluorescence on fluorescein angiography and a corresponding loss of autofluorescence. Optical coherence tomography of both eyes revealed complete RPE and inner segment/outer segment junction loss with adjacent areas of thickening at the level of the RPE. Bilateral diffuse uveal melanocytic proliferation was diagnosed based on these clinical findings, and a systemic evaluation for malignancy revealed metastatic endometrial adenocarcinoma. Both autofluorescence and optical coherence tomography demonstrated unique imaging characteristics that correlated with the reported histopathology of bilateral diffuse uveal melanocytic proliferation. These imaging modalities can contribute to the rapid and accurate diagnosis of bilateral diffuse uveal melanocytic proliferation.

Intraocular metastasis of testicular natural killer T-cell lymphoma with diffuse retinal pigment epithelium changes

PURPOSE

The purpose of this study was to report the first confirmed case of testicular natural killer T-cell lymphoma with bilateral intraocular metastasis.

METHODS

The author presents a chart review of a patient with testicular natural killer T-cell lymphoma metastasis to both eyes. This patient was treated with systemic chemotherapy, radiation, and intravitreal injections of methotrexate.

RESULTS

The author identified one case of a patient with the diagnosis of bilateral metastatic natural killer T-cell lymphoma with ocular involvement treated with intravitreal methotrexate. After treatment, the patient developed diffuse widespread retinal pigment epithelium alterations in giraffe-like patterns.

CONCLUSION

This represents a clinical case of a patient with primary testicular natural killer T-cell lymphoma and ocular metastasis with posttreatment retinal changes resembling bilateral diffuse uveal melanocytic proliferation.

Clear cell carcinoma of the endometrium causing paraneoplastic retinopathy: case report and review of the literature

We reviewed the literature for cases in which gynecologic malignancies caused paraneoplastic retinopathy and ultimately led to blindness. Twenty-eight cases were derived from the literature, and one unique case is described from our institution. Of these 28 cases, 14 patients were diagnosed with endometrial cancer, 7 with ovarian cancer, 5 with cervical cancer, 1 fallopian tube cancer and 1 with concomitant endometrial and ovarian cancers. The average age of patients at the time of diagnosis was 64 years (range, 35-89 years). Typically, ocular manifestations antedate symptoms of the underlying carcinoma by 3-12 months. Information regarding the interval from visual symptoms to time of death is limited, but ranges from several months to several years. Our report is the first to document a clear cell carcinoma of the endometrium causing paraneoplastic retinopathy and is the first to review all gynecologic malignancies associated with visual paraneoplastic syndromes.

Loss of Retinal Pigment Epithelium Associated with Bilateral Diffuse Uveal Melanocytic Proliferation

A 69-year-old woman was evaluated for poor visual acuity in both eyes despite recent cataract extractions. She had bilateral distinct melanocytic lesions in the posterior uvea and retinal pigment epithelial loss over these lesions and over normal-appearing choroid. Fluorescein angiography showed patchy areas of mottled hypofluorescence and hyperfluorescence. Optical coherence tomography demonstrated focal deposition of material over atrophic retinal pigment epithelium. Electroretinography showed decreased a- and b-wave amplitudes under scotopic and photopic conditions. The diagnosis of bilateral diffuse uveal melanocytic proliferation immediately led to the discovery of bronchogenic carcinoma and the patient died 10 days later. This case study suggests that different paraneoplastic stimuli may be operational over the retinal pigment epithelium and uveal melanocytes and that certain features of bilateral diffuse uveal melanocytic proliferation and cancer-associated retinopathy may coexist.

Fundus Autofluorescence Imaging of Diffuse Uveal Melanocytic Proliferation

Fundus autofluorescence imaging (FAF) in a case of diffuse uveal melanocytic proliferation is described in this study. It is a rare chorioretinopathy associated with systemic cancer, for which the exact pathological mechanisms are poorly understood. FAF-imaging revealed a diffuse background of hyper-autofluorescence associated with diffuse orange pigment deposition and islands of persistent hypo-fluorescence corresponding to loss of retinal pigment epithelium (RPE). In this disorder, increasingly smaller spots of FAF hypo-fluorescence were found from the center to the periphery of the affected retina. Fluorescein angiography demonstrated a negative of the FAF-images. FAF hypo-autofluorescence corresponded to optical coherence tomography (OCT) thinning or absence of the RPE-layer. Conversely, FAF hyper-autofluorescence correlated to thickening of the RPE-layer on OCT. The case demonstrates that FAF can be useful for the diagnosis of diffuse uveal melanocytic proliferation and offers greater insight into the pathophysiology of this disease.

Cancer-associated nummular loss of the retinal pigment epithelium

Purpose

To report a case of cancer-associated nummular loss of the retinal pigment epithelium.

Methods

A 47-year-old man with a history of hepatocellular carcinoma presented with three weeks of bilateral visual loss. His best-corrected visual acuity was 20/40 in each eye. He had multiple round confluent grayish-brown patches at the level of retinal pigment epithelium, and no pigmented choroidal lesions. Fluorescein angiography showed circular areas of transmission defect and indocyanine green angiography showed early hyperfluorescence, corresponding with the multiple round confluent patches.

Conclusions

We report a case of visual paraneoplastic syndrome which showed nummular loss of the pigment epithelial cells which distinguishes the clinical component of BDUMP syndrome.

Bilateral diffuse uveal melanocytic proliferation and loss of retinal pigment epithelium

PURPOSE

To describe a fundus autofluorescent photographic pattern in a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) with occult esophageal carcinoma.

METHODS

Observational case report.

RESULTS

Color photography captured multiple round areas of discoloration throughout the fundus in a background of orange pigmentation that may have represented a lipofuscin-laden retinal pigment epithelium (RPE). Autofluorescence photography showed extensive nummular areas of hypoautofluorescence interspersed between areas of hyperautofluorescence as a result of extensive deposition of lipofuscin within the RPE.

CONCLUSION

Our case attests to the utility of autofluorescence photography as a sensitive, noninvasive imaging modality for the early detection of BDUMP.