Peripapillary Neuroendocrine Carcinoma Metastasis: A Novel Approach to Treatment

Peripapillary and circumpapillary retinal intraocular metastases are rare and present a treatment challenge for ophthalmologists because of the high risk of iatrogenic injury to the optic nerve. There are no clear guidelines on the management of these lesions, and many clinicians will initially observe for improvement of the metastases with systemic chemotherapy before considering local therapy with external beam radiation. Radiation to the optic disc carries a significant risk of injuring the optic nerve, leading to worsening of vision. Alternative treatment approaches are needed. We present a patient with large-cell neuroendocrine carcinoma with metastasis to the peripapillary retina who was treated with intravitreal topotecan and with intravitreal aflibercept. Serial fundus photos, ultrasound, and optical coherence tomography demonstrated a reduction in size of the lesion and a decrease in subretinal fluid with intravitreal topotecan and aflibercept. In addition, visual acuity was stabilized during treatment. Intravitreal chemotherapy for intraocular metastases in vision-sensitive areas such as the peripapillary retina may be a viable alternative for patients who seek to preserve their vision and maintain their quality of life.

Ockham's razor is not so sharp

A 39-year-old male with newly diagnosed HIV had cavitary pneumonia initially attributed to Pneumocystis jirovecii but actually caused by Rhodococcus equi. After neurological deterioration, he was found to have intracerebral lesions caused by Toxoplasma gondii. This case underscores the inability to rely on the search for a unifying diagnosis (Ockham's Razor) in HIV-infected patients.