Circumpapillary Metastasis with Optic Neuropathy

By Paul T. Finger, MD

Description

Malignant tumors from other parts of the body can spread in and around the eye. These tumors may never be discovered unless they affect the vision, are visible in the iris, or push the eye forward.

Symptoms

Most patients with choroidal metastasis have no symptoms, that is unless the tumor affects the central macular retina, optic nerve or the front of the eye (iris). For example, this patient’s tumor (pictured above) affected his optic nerve, caused decreased vision and floaters (spots in his vision).

Diagnosis

Most patients have a history of primary cancer (as in this case), and the tumor’s characteristics are typical of metastatic disease. This tumor was yellow-white, poorly circumscribed, less than 3 mm thick and causing congestion with vascular compromise of the optic nerve.

Treatments

As with this patient, most choroidal metastasis will resolve with external beam radiation therapy. Like many patients treated for metastatic disease, this patient received 30 Gy in 10 daily fractions. Other treatment protocols (doses) may be different, depending on the type of primary tumor.

Dr. Finger currently recommends that orbital radiation therapy for metastatic disease be performed in 180-200 cGy daily fractions. This is due to the unique sensitivity of the eye and lacrimal (tear) systems. With improvements in systemic therapy, patients are living longer and thus developing late radiation complications. Dr. Finger believes these complications will be less likely if the radiation is delivered in smaller daily fractions.

Additional info

Anterior Uveal Metastasis

By Paul T. Finger, MD

Description

Metastatic Breast Cancer
Metastatic Breast Cancer

Intraocular metastasis is the most common malignant intraocular tumor and may occur in as many as 10% of patients with metastatic cancer. Most of these tumors go undetected unless they affect vision and become symptomatic.

Metastatic breast cancer is the most common in women and lung is the most common in men. Other primary sites include prostate, skin, kidney, colon and thyroid. Leukemia and lymphoma also occur in the eye.

Less than 10 percent of intraocular metastatic tumors are located in the anterior part of the eye.

Metastatic Lung Cancer
Metastatic Lung Cancer

Symptoms

Most patients with iris metastasis present either with a visible cance (see photographs) or tumor-related “secondary” glaucoma. Glaucoma can cause foggy vision, halos around lights and headaches (brow aches). These “symptomatic” patients that come to or are sent for ophthalmic examination.

Most iris metastasis patients either have a history of cancer or are found to have a primary source of the tumor (on systemic examination). It is important to perform complete systemic survey when intraocular metastasis is suspected. This examination should include radiographic imaging (staging).

The New York Eye Cancer Center protocol involves whole body, scalp-to-toes PET/CT.

The reason is that though most intraocular cancers come from the lung and breast, there exist multiple less common “source” primary cancers. PET/CT evaluates the entire body. Consultation with an adult or pediatric medical oncologist should be obtained.

Despite systemic evalutions, sometimes patients will have no detectable primary cancer. Most of these tumors will later be found to originate from the lung (particularly in men). In these cases (where no primary cancer is found), the intraocular tumor becomes the only tissue that can be used to direct the search for its site of origin. Thus, biopsy of an anterior segment metastasis may become necessary. Biopsy techniques include: fine-needle aspiration biopsy, transcorneal tumor excision, and the relatively safe “Finger Iridectomy Technique (FIT).”

Treatments

Advanced anterior iris and ciliary body metastases can be difficult to manage. Radiation therapy alone or in combination with intraocular anti-VEGF drug therapy may be used to control the tumor, protect vision and conserve the eye. If left untreated, metastatic cancer in the iris can cause glaucoma and a blind painful eye. Thankfully, symptomatic anterior segment metastases are much less common than choroidal metastasis.

When the diagnosis of intraocular metastasis is made or suspected, eye cancer specialists always dilate and examine both eyes. This is because metastases can be both bilateral and multifocal. Computed tomography or magnetic resonance imaging of the brain and lungs should be performed due to a high incidence of concurrent metastases.

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"Very well treated by Dr. Finger. He explained everything I needed to know about my issue with detail and attention, putting me at ease and giving me confidence to handle this problem for the rest of my life.”
– N.N.

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