Systemic disease and neuro-ophthalmology: annual update 2000 (Part I)

Cancer-associated Retinopathy with Neuroendocrine Combined Large-cell Lung Carcinoma and Adenocarcinoma

We herein report the case of a 74-year-old woman with a lung tumor. She presented with complaints of blurred and rapid, progressively impaired vision. A visual field examination revealed bilateral concentric contraction of the visual field and a ring scotoma in the right eye. She was diagnosed with cancer-associated retinopathy (CAR) combined with large-cell neuroendocrine carcinoma (LCNEC) of the lung via a visual field examination and underwent thoracoscopic surgery. CAR has been mostly associated with small-cell lung cancer (SCLC). Combined LCNEC is relatively rare and accounts for 10.6% of all LCNECs. This is the first case report of CAR-combined LCNEC.

Paraneoplastic vitelliform retinopathy in a patient with treated choroidal melanoma

PURPOSE

To describe a peculiar case of paraneoplastic vitelliform maculopathy/retinopathy in a patient with treated choroidal melanoma.

METHODS

A case report of a 58-year-old woman with a history of treated choroidal melanoma 16 years before developing visual changes in the setting of metastatic choroidal melanoma.

RESULTS

We demonstrate bilateral, multifocal vitelliform subretinal lesions and focal, neurosensory retinal detachment associated with metastatic melanoma.

CONCLUSION

Paraneoplastic vitelliform maculopathy/retinopathy should be considered in patients with or without a history of melanoma, who have unexplained serous, vitelliform retinal detachments, especially with atypical or absence of leakage on fluorescein angiography.

Diagnostic features of the autoimmune retinopathies

The term autoimmune retinopathy encompasses a spectrum of rare autoimmune diseases that affect retinal function, often but not exclusively at the level of the photoreceptor. They typically present with painless visual loss, which may be accompanied by normal fundus examination. Some are progressive, often rapidly. They present a diagnostic challenge because there are no standardised clinical or laboratory based diagnostic criteria. Included within the spectrum are cancer-associated retinopathy, melanoma-associated retinopathy and presumed non-paraneoplastic autoimmune retinopathy. Differentiation from other retinopathies can be challenging, with overlap in symptoms, signs, and investigation findings, and an absence of pathognomonic features. However, technological developments in ophthalmic imaging and serological investigation over the past decade are adding novel dimensions to the investigation and classification of patients with these rare diseases. This review addresses the clinical, imaging, and serological features of the autoimmune retinopathies, and discusses the relative strengths and limitations of candidate diagnostic features.

Autoimmune retinopathies: a report of 3 cases

PURPOSE

To describe 3 representative cases of autoimmune retinopathy (AIR).

METHODS

Clinical records of patients with a diagnosis of AIR were analyzed for demographic data, clinical findings, ancillary and laboratory tests, and treatment employed.

RESULTS

Three female patients diagnosed with AIR had bilateral reduction of electroretinogram amplitudes and elevation of visual field threshold within the central 30 degrees of the visual field that was disproportionately more severe than the clinical findings of retinal degeneration. The diagnoses were cancer-associated retinopathy, non-neoplastic AIR, and hereditary retinal dystrophy with secondary inflammation. Optic nerve involvement was also present in all cases. The patient with non-neoplastic AIR was successfully treated with systemic corticosteroids and immunomodulatory agents.

CONCLUSION

High index of suspicion is essential for an early diagnosis of AIR. Visual function and electrophysiological tests should be included in the initial workup of patients who present with suggestive clinical signs and symptoms of AIR.

Bilateral paraneoplastic optic neuropathy and unilateral retinal compromise in association with prostate cancer: a differential diagnostic challenge in a patient with unexplained visual loss

We report a 77-year-old Caucasian man with a 1-year complaint of unexplained visual loss and a 4-year history of prostate cancer. A complete ophthalmologic exam, Goldmann visual fields (GVFs), intravenous fluorescein angiography (IVFA), macular and disc optical coherence tomography (OCT), pattern-reversal visual evoked potentials (PVEPs), and flash electroretinograms (ERGs) were performed. On examination, visual acuity was reduced bilaterally. Fundus exam showed juxtapapillary changes (OS > OD) and, in OS, disc pallor, peripheral RPE dropout and whitish retinal discoloration along the arcades. OCTs were normal OU. Cancer-associated retinopathy (CAR) was suspected. A flash ERG was normal OD and markedly reduced and electronegative OS. An IVFA showed bilateral juxtapapillary staining and changes highly suggestive of sequelae of central retinal artery occlusion (CRAO) OS , in which a cilioretinal artery existed along the papillomacular bundle. GVFs showed bilateral blind spot enlargement and centrocecal scotomas, and PVEPs were delayed. These findings suggested cancer-associated optic neuropathy (CAON), confirmed by presence of anti-optic nerve autoantibodies (auto-Abs). No anti-retinal auto-Abs were found. CAON is a less common paraneoplastic manifestation than CAR and it is rarely observed in association with prostate cancer. A combination of visual function testing methods permitted the recognition, in this highly unusual case, of the concurrent presence of unilateral ERG changes most likely attributable to CRAO complications in OS, in all likelihood unrelated to CAON, and not to be confused with unilateral CAR. Auto-Ab testing in combination with visual function tests helps achieve a better understanding of the pathophysiology of vision loss in paraneoplastic visual syndromes.

Cancer associated retinopathy (CAR): An autoimmune-mediated paraneoplastic syndrome

Cancer associated retinopathy (CAR) is an uncommon paraneoplastic retinopathy in which antibodies are directed against retinal antigens. Vision loss is associated with abnormal ERG findings. Few case reports and lack of controlled clinical trials make management of this syndrome especially challenging for the clinician. Herein, we describe the clinical, histopathologic and electrophysiologic features of CAR, along with a summary of previously employed management options. Cancer associated retinopathy syndrome has been recognized as a paraneoplastic disorder, most commonly associated with small cell lung cancer, in which cross-reacting autoantibodies against retinal antigen cause retinal dysfunction. Bilateral vision loss as a result of both rod and cone dysfunction in CAR may occur over a period of months, and visual symptoms may precede diagnosis of the systemic malignancy. The heterogeneity in antigens that have been identified as targets of antibody-mediated retinal damage perhaps help to explain the complexity of symptoms and the treatment challenges posed by patients with CAR.

Small cell carcinoma of the uterine corpus manifesting with visual dysfunction

BACKGROUND

Small cell carcinoma in the uterine corpus rather than the endometrium has not been reported yet which resembles a uterine leiomyosarcoma on an imaging study. Furthermore, gynecologic malignancies manifested as a visual dysfunction render the early suspicion and accurate diagnosis a difficult proposition.

CASE

A 57-year-old Korean woman was referred to the Department of Obstetrics and Gynecology due to incidentally detected uterine mass. She had been suffering from a visual loss for several weeks. This uterine mass mimicking a leiomyosarcoma on pelvis MRI was identified to be a small cell carcinoma via a transvaginal gun biopsy and consequent immunostaining. The patient was then scheduled to undergo a regimen of chemotherapy with etoposide and carboplatin.

CONCLUSION

Small cell carcinoma may arise from the uterine corpus rather than the endometrium and may also be accompanied by visual symptoms.

Paraneoplastic syndromes associated with visual loss

PURPOSE OF REVIEW

The recent literature was reviewed to analyze the developments in the diagnosis, pathogenesis, and immunology of this group of paraneoplastic syndromes. Clinical features and pathologic findings are summarized.

RECENT FINDINGS

The mechanism of cell death in cancer-associated retinopathy appears to occur through apoptotic pathways. Caspase inhibitors and a calcium antagonist have been used in animal models to block or suppress the effect of the antirecoverin antibodies on the retina with significant response. These agents are possible treatment options for cancer-associated retinopathy. Aberrant expression of recoverin by tumor cells does not necessarily induce antirecoverin antibodies and cancer-associated retinopathy. Many tumors, not just those producing the clinical picture of cancer-associated retinopathy, have been shown to express recoverin. Recoverin appears to play a functional role in tumor cells, and antirecoverin antibodies may have tumor-suppressing effects. Further research into this area may help design epitope-based immunotherapy for patients with recoverin-expressing tumors. Further evidence has emerged to support the initial observation that depolarizing bipolar cells are the likely retinal target in melanoma-associated retinopathy. Intravitreal injection of melanoma-associated retinopathy serum produced electroretinogram changes in animals very similar to the clinical findings in humans. Many new antibodies and antigens had been discovered to be linked to various paraneoplastic syndromes. Anti-collapsing response-mediating protein-5 is likely to be an important one; it was found to be the second most common autoantibody related to paraneoplastic neurologic syndromes.

SUMMARY

Further research into the functional role of recoverin in cancer cells may advance our understanding in cancer immunology. Immunotherapy may be possible if a specific epitope of recoverin can be found to contain the antigenic site for antitumor antibodies and not cross-react with retinal antigens. Research into the pathogenesis of the other paraneoplastic syndromes is required for a better understanding and treatment of these rare conditions. The missing link between primary cutaneous melanoma and uveal melanocytes still eludes investigators in bilateral diffuse uveal melanocytic proliferation. The discovery of the missing link may provide us with some understanding of the development of uveal melanoma.