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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 1  |  Page : 19-21

Utility of spectral domain optical coherence tomography in a case of choroidal metastasis to monitor response to treatment


Department of Vitreoretina, K B H Bachooali Charitable Ophthalmic and ENT Hospital, Mumbai, Maharashtra, India

Date of Web Publication23-Mar-2018

Correspondence Address:
Dr. Anand Subramanyam
Department of Vitreoretinal and Uvea, K B H Bachooali Charitable Ophthalmic and ENT Hospital, 58/60, Jehangir Merwanji Road, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/oji.oji_5_18

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  Abstract 


Serial spectral domain optical coherence tomography (SD-OCT) images can be applied to monitor the effectiveness of systemic treatment in choroidal metastasis. Besides, it can be used as a guide to shifting to alternate therapy in nonresponding cases. SD-OCT was performed in a patient of primary adenocarcinoma of the lung with choroidal metastasis in the right eye. SD-OCT revealed neurosensory detachment overlying metastasis and involving macula. The patient was started on chemotherapy and external beam radiotherapy. After treatment completion, neurosensory detachment resolved completely with the regaining of normal foveal contour and improvement in visual acuity.

Keywords: Choroidal metastasis, response, spectral domain optical coherence tomography, systemic treatment


How to cite this article:
Patil PP, Subramanyam A. Utility of spectral domain optical coherence tomography in a case of choroidal metastasis to monitor response to treatment. Oncol J India 2018;2:19-21

How to cite this URL:
Patil PP, Subramanyam A. Utility of spectral domain optical coherence tomography in a case of choroidal metastasis to monitor response to treatment. Oncol J India [serial online] 2018 [cited 2019 Feb 19];2:19-21. Available from: http://www.ojionline.org/text.asp?2018/2/1/19/228326




  Introduction Top


Choroid possesses a highly vascularized network of choriocapillaries forming a thin sheet. Blood velocity in the choroid is slower than that of the retina, making choroid a potential site for metastasis.[1] Choroidal metastasis is the most frequent ocular tumor.[2],[3] In choroidal metastasis, primary tumors are located more frequently in the lungs or breasts.[3]

Spectral domain optical coherence tomography (SD-OCT) allows us to image different layers of the retina without histological examination.[4] Although SD-OCT is not the primary diagnostic modality for choroidal metastasis, optical coherence tomography (OCT) features have been described for the same.[5] There are associated retinal changes observed on histopathological examination in choroidal metastasis.[6] SD-OCT might be useful in tracking these changes associated with choroidal metastasis. We present a case of the right eye choroidal metastasis with serial follow-up on SD-OCT.


  Case Report Top


A 64-year-old-male was referred to our hospital for ophthalmic evaluation of complaints about the diminution of vision of the right eye for one month. He was a known case of biopsy-proven adenocarcinoma of the lung.

The patient underwent thorough ophthalmic evaluation. His visual acuity on Snellen's visual acuity chart was finger counting at ½ m in the right eye, not improving with pinhole, and 6/6 in the left eye. His slit lamp evaluation did not reveal any remarkable alteration. Intraocular pressure in both eyes was 13 mmHg. Fundus examination of the right eye showed multiple cream-colored yellow subretinal elevated round lesions in the superotemporal quadrant involving posterior pole and macula. There was associated exudative retinal detachment [Figure 1]a. Ultrasound of the right eye showed diffuse choroidal mass lesion in the superotemporal quadrant of high surface reflectivity and moderate-to-high internal reflectivity. Choroidal thickness was 3.13 mm. The base diameter was 8.07 mm. There was associated overlying exudative retinal detachment [Figure 1]b. His left eye fundus evaluation did not reveal any remarkable alterations. SD-OCT of the right eye, through the macula, demonstrated neurosensory detachment, multiple hyperreflective dots lesions along the outer margin of the retina, in the subretinal space, and along the inner margin of retinal pigment epithelium (RPE)-choriocapillary complex. Central foveal thickness (CFT) was 611 μ [Figure 1]c.
Figure 1: (a) Color fundus photograph of right eye showing creamish yellow subretinal lesions with overlying exudative retinal detachment involving macula (white arrows) and pigmentary changes in retinal pigment epithelium (black asterisk). (b) B-scan showing diffuse choroidal thickening with overlying retinal detachment (white arrow). (c) Spectral domain optical coherence tomography of the right eye showing neurosensory detachment, hyperreflective dot aggregates (white asterisk) underneath the neurosensory retina, in subretinal space, along with the inner margin of retinal pigment epithelium-choriocapillary complex

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Thus, the diagnosis of choroidal metastasis secondary to adenocarcinoma of the lung was made.

After receiving one cycle of palliative chemotherapy with etoposide and cisplatin based combination regimen, the right eye showed no marked improvement in visual acuity while fundoscopy showed a marginal reduction in the size of choroidal lesions and exudative retinal detachment [Figure 2]a. SD-OCT showed a decrease in neurosensory detachment but the persistence of hyperreflective dot echoes along the outer margin of the retina and along the inner margin of RPE-choriocapillary complex. CFT reduced to 493 μ [Figure 2]b.
Figure 2: (a) Color fundus photograph of the right eye showing decreased exudation (white arrows). (b) Spectral domain optical coherence tomography showing persistence of hyperreflective dot aggregates (white asterisk) and decrease in subretinal fluid

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The patient received three more chemotherapy cycles with the same etoposide and cisplatin regimen. Due to systemic toxicity, the palliative chemotherapy schedule changed to carboplatin and pemetrexed based regimen and the patient received four cycles of carboplatin and pemetrexed based palliative chemotherapy. His visual acuity improved to 6/24 in the right eye. On fundus evaluation of the right eye, the choroidal lesions had flattened with a resolution of exudative retinal detachment [Figure 3]a. SD-OCT at this time showed resolution of neurosensory detachment, disappearance of hyperreflective lesions and regaining of a normal foveal contour with CFT 191 μ [Figure 3]b.
Figure 3: (a) Color fundus photograph of the right eye showing a flattening of metastatic lesions. (b) Spectral domain optical coherence tomography of the right eye with normal foveal contour

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  Discussion Top


Diagnosis of choroidal tumors has always been difficult as there are no noninvasive tests to detect them. Moreover, diagnosis of choroidal metastasis is mainly based on clinical evaluation, ophthalmic ultrasound, and systemic diagnosis of primary carcinoma.[6] The posterior pole is a common site of involvement in choroidal metastasis.[7] Hence, OCT can be used as a crucial tool for diagnosis and management of choroidal metastasis. Features of choroidal tumors on OCT have been described, but OCT is not useful in differentiating between tumor types.[8] SD-OCT and enhanced depth imaging OCT have been used to evaluate the features of choroidal metastasis.[6],[9],[10]

Features of choroidal metastasis on OCT have been described as dome-shaped elevation of the retina, hyperreflective points in the neurosensory retina (corresponding to retinal compromise by cancer cells), a double hyperreflective band at the RPE-choriocapillary complex, shadowing in some parts of the RPE-choriocapillary complex, increased thickness of the RPE-choriocapillary complex, areas of no reflectance within the neurosensory retina, suggestive of splitting of intraretinal layers.[9]

The presence of neurosensory detachment and the presence of hyperreflective dot-like deposits in subretinal space, beneath the retinal surface, and above RPE-choriocapillary complex are characteristic features observed on SD-OCT in our case. Nevertheless, we did not observe intraretinal splitting as observed by others.[9] As chemotherapy cycles progressed, neurosensory detachment regressed and normal foveal contour was regained after seven cycles of chemotherapy. In our report, SD-OCT characteristics were matched with those described by other studies.[9] Our case points out to the fact that OCT can be used as an effective tool to monitor response to chemotherapy in choroidal metastasis.

In our particular case, the patient responded to chemotherapy. However, in unresponsive cases, nonresolving neurosensory detachment on SD-OCT could be utilized as a guideline for switching to alternative therapeutic modality in choroidal metastasis. Thus, SD-OCT, being a noninvasive and quick technique for evaluation of histological layers of the retina, can be used as a tool to monitor treatment response to choroidal metastasis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nickla DL, Wallman J. The multifunctional choroid. Prog Retin Eye Res 2010;29:144-68.  Back to cited text no. 1
[PUBMED]    
2.
Duke JR, Walsh FB. Metastatic carcinoma to the retina. Am J Ophthalmol 1959;47:44-8.  Back to cited text no. 2
    
3.
Koenig RP, Johnson DL, Monahan RH. Bronchogenic carcinoma with metastases to the retina. Am J Ophthalmol 1963;56:827-9.  Back to cited text no. 3
    
4.
Barak A, Neudorfer M, Heilweil G, Merimsky O, Lowenstein A, Inbar M, et al. Decreased prevalence of asymptomatic choroidal metastasis in disseminated breast and lung cancer: Argument against screening. Br J Ophthalmol 2007;91:74-5.  Back to cited text no. 4
    
5.
Hee MR, Izatt JA, Swanson EA, Huang D, Schuman JS, Lin CP, et al. Optical coherence tomography of the human retina. Arch Ophthalmol 1995;113:325-32.  Back to cited text no. 5
    
6.
Al-Dahmash SA, Shields CL, Kaliki S, Johnson T, Shields JA. Enhanced depth imaging optical coherence tomography of choroidal metastasis in 14 eyes. Retina 2014;34:1588-93.  Back to cited text no. 6
    
7.
Shields JA, Shields CL. In: Intraocular Tumors. An Atlas and Textbook. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; Metastatic Tumors to the Uvea, Retina, and Optic Disc; 2008. p. 198-227.  Back to cited text no. 7
    
8.
Shields CL, Shields JA, Gross NE, Schwartz GP, Lally SE. Survey of 520 eyes with uveal metastases. Ophthalmology 1997;104:1265-76.  Back to cited text no. 8
    
9.
Schaudig U, Hassenstein A, Bernd A, Walter A, Richard G. Limitations of imaging choroidal tumors in vivo by optical coherence tomography. Graefes Arch Clin Exp Ophthalmol 1998;236:588-92.  Back to cited text no. 9
    
10.
Arevalo JF, Fernandez CF, Garcia RA. Optical coherence tomography characteristics of choroidal metastasis. Ophthalmology 2005;112:1612-9.  Back to cited text no. 10
    


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