Atypical presentation of lung carcinoma

YS Kamath, P Gupta, KA Rao, SS Bhat 
 Department of Ophthalmology, Kasturba Medical College, Manipal, Karnataka, India

Correspondence Address:
Y S Kamath
Department of Ophthalmology, Kasturba Medical College, Manipal, Karnataka
India

Full Text

Choroidalmetastasis with symptoms of blurred vision may rarely be the initial presentation of lung carcinoma. [1],[2],[3] We report a case wherein a middle-aged patient presented to us with presbyopic symptoms, but was detected to have primary lung carcinoma with intraocular metastasis.

A 40-year-old farmer was evaluated in an eye camp, where he presented with a complaint of difficulty in reading small letters. Considering his age, presbyopia was initially suspected. However, a disparity in the visual acuity of both eyes prompted a detailed evaluation. His best corrected visual acuity was 20/20, N6 in his right eye, and 20/60, N12 in his left eye. Anterior segment evaluation was normal in his right eye but revealed a relative afferent pupillary defect in his left eye. His fundus examination at the base hospital showed a choroidal mass around 4 disc diameters in size with overlying serous retinal detachment in both eyes, with macular involvement in his left eye [Figure 1]. Systemic history of cough four months ago, occasional low-grade fever, but no significant weight loss or tobacco use was elicited. Mantoux test was negative and chest X-ray reported as normal. He was referred to the physician for evaluation of the cough but was lost to follow-up.{Figure 1}

After a month, he reported with further deterioration of vision and cough. A fundus fluorescein angiogram [Figure 2], and repeat B-scan ultrasonography [Figure 3] showed an increase in size of lesions with features of choroidal metastasis. A chest computed tomography (CT) scan done showed a lung nodule with spiculated margins in the medial segment of the right middle lobe with metastatic lesions seen in the liver and lobular enhancing lymph nodal mass lesion in the carinal region and multiple enlarged mediastinal lymph nodes [Figure 4]. Bronchial brushing samples retrieved by fiberoptic bronchoscopy were detected to be smear-positive for non-small-cell lung carcinoma.{Figure 2}{Figure 3}{Figure 4}

Choroidal metastasis is most common from breast carcinoma in women, and lung carcinoma in men. [4] In their case series, Shields et al., reported that of the patients presenting only with uveal metastasis without awareness of systemic cancer, 35% had the primary source in the lung. [4]

In the presence of a history of chronic cough in our middle-aged non-smoker, infectious etiology of tuberculosis was initially considered. Intraocular tuberculosis can present as a large choroidal mass called tuberculoma, which may cause visual disturbance if the macula is involved. [5] However in our case, the Mantoux test was negative and the fundus fluorescein angiogram revealed an early hyperfluoresence in the choroidal mass suggestive of metastasis.

Ocular metastasis of non-small-cell lung carcinoma has been reported to respond well to systemic chemotherapy and intravitreal bevacizumab therapy. [6],[7] The mean survival in patients with disseminated lung cancer and choroidal metastasis ranges from 1.9 months to 6 months. [8] Unfortunately, despite a diagnosis, the treatment could not be initiated as the patient was lost to follow-up.

To conclude, a disparity in presbyopic status in a peripheral camp was noted, evaluated due to a high index of suspicion and found to be a manifestation of a life-threatening problem.

 Acknowledgments

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