Ultrabiomicroscopic imaging of choroidal metastases underlying an anterior scleritis

Lucas A Garza-Garza; Raul E Ruiz-Lozano; Eugenia M Ramos-Davila; Carlos Alvarez-Guzman

doi:10.4103/pajo.pajo_95_21

CASE REPORT

Year : 2021 | Volume : 3 | Issue : 1 | Page : 25

Ultrabiomicroscopic imaging of choroidal metastases underlying an anterior scleritis

Lucas A Garza-Garza, Raul E Ruiz-Lozano, Eugenia M Ramos-Davila, Carlos Alvarez-Guzman
Department of Ophthalmology, School of Medicine and Health Sciences, Tecnológico de Monterrey, Monterrey, México

Date of Submission	20-May-2021
Date of Decision	03-Jul-2021
Date of Acceptance	05-Jul-2021
Date of Web Publication	24-Aug-2021

Correspondence Address:
Dr. Carlos Alvarez-Guzman
Av. Batallon de San Patricio #112. Col. Real de San Agustin, N.L. CP. 66278
México

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_95_21

Abstract

Tumor-associated masquerading anterior scleritis (AS) is a rare syndrome with few case reports in the medical literature. Imaging studies play a crucial role in the correct diagnosis of this entity. Ultrabiomicroscopy (UBM) is a vital imaging tool in the study of anterior segment lesions and enables early diagnosis and treatment in these patients. We report the clinical and ultrabiomicroscopic findings of a patient with tumor-associated masquerading AS due to choroidal metastases from lung adenocarcinoma. A 65-year-old male patient with stage IV lung adenocarcinoma in remission presented with red eye and intense pain in his left eye refractory to nonsteroidal anti-inflammatory drugs. An AS was diagnosed and after no treatment response, ocular ultrasound (US), and UBM were ordered. Choroidal metastases were evidenced underlying the exact area of scleral inflammation. While the characteristics of metastases by US match those previously reported in the literature, UBM reveals novel characteristics, such as irregular thickening, intralesional heterogeneity, and a “lumpy-bumpy” pattern.

Keywords: Lung adenocarcinoma, masquerading syndrome, ocular metastases, scleritis

How to cite this article:
Garza-Garza LA, Ruiz-Lozano RE, Ramos-Davila EM, Alvarez-Guzman C. Ultrabiomicroscopic imaging of choroidal metastases underlying an anterior scleritis. Pan Am J Ophthalmol 2021;3:25

How to cite this URL:
Garza-Garza LA, Ruiz-Lozano RE, Ramos-Davila EM, Alvarez-Guzman C. Ultrabiomicroscopic imaging of choroidal metastases underlying an anterior scleritis. Pan Am J Ophthalmol [serial online] 2021 [cited 2023 Mar 28];3:25. Available from: https://www.thepajo.org/text.asp?2021/3/1/25/324521

Introduction

Metastases represent the most common intraocular malignancy in adults, with most of them originating in lung or breast neoplasms.^[1],[2] As most intraocular metastases develop in the choroid, particularly in the posterior pole, presenting symptoms and signs include deterioration of visual acuity, scotomata, and the visualization of a subretinal mass through biomicroscopy.^[1] Less commonly, metastases affect the anterior portion of the uveal tract and can present clinically as pain or masquerade as inflammatory diseases such as scleritis.^[1],[3] Masquerading scleritis is an unusual presentation of choroidal metastases.^{[2],[3],[4],[5]} Identifying the underlying pathology in these patients is difficult and a time lag to final diagnosis is common.^[4] Imaging studies can often aid the clinician by evidencing abnormal structures.^[1],[4],[6] Ultrabiomicroscopy (UBM) is an effective imaging modality which can produce microscopic, high-resolution pictures of the ocular structures.^[7],[8],[9] With UBM, metastases to the uveal tract are usually visualized as dome-shaped, heterogeneous, and poorly defined masses.^[7],[8],[9] Only few reports on the imaging characteristics of choroidal metastases underlying a masquerading anterior scleritis (AS) have been reported.

Case Report

A 65-year-old male presented with a 1-month history of insidious and severe pain in his left eye unresponsive to oral nonsteroidal anti-inflammatory drugs. He had a medical history of a stage IV lung adenocarcinoma treated with lobectomy, chemo-and radiotherapy, apparently on remission, diagnosed 6 months prior. Best-corrected visual acuity was 20/40 in both eyes. Clinical assessment of the right eye was unremarkable. On the left eye, dilated and tortuous episcleral vessels with a violaceus hue were visible in the temporal and inferior regions and the pain was elicited with palpation [Figure 1]a and [Figure 1]b. No whitening of the episcleral plexus was observed with topical brimonidine. Posterior pole examination was within the normal limits in both eyes. A diagnosis of AS was made and oral prednisone (1 mg/kg daily) and flurbiprofen (100 mg BID) were initiated. The patient returned 2 weeks later with no response. An infectious etiology was considered and oral valaciclovir (500 mg BID) was initiated suspecting a herpes simplex associated AS. After obtaining no response, a masquerading syndrome was suspected, and an ocular ultrasound (US) with UBM was ordered. US was undertaken using a high-frequency 20MHz probe. US of the right eye was within the normal limits. US of the left eye is shown in [Figure 1]c, [Figure 1]d, [Figure 1]e. It revealed a flat choroidal lesion in the inferotemporal quadrant, 6.7 mm away from the optic disc, which topographically correlated to the site of scleral inflammation. The lesion was homogeneous, irregular, lobulated, and possessed a medium-high reflectivity on A mode. It measured 13.04 mm × 13.60 mm × 2.08 mm, extended to the peripheral choroid and spared the ciliary body. UBM examination [Figure 1]f, [Figure 1]g, [Figure 1]h revealed a flat but remarkably irregular thickened choroid in a “lumpy-bumpy” pattern, with an heterogenous, diminished internal echogenicity. In addition, an intrascleral area of hypoechogenicity was visible, which could represent inflammatory liquid or scleral infiltration of neoplastic cells. The ciliary body appeared unaffected in the B-mode US as well as UBM. Findings on US and UBM were suggestive of neoplastic infiltration of the choroid. A diagnosis of choroidal metastases masquerading as AS was made and the patient was referred to the oncology service for treatment evaluation and palliative pain control. After evaluation and counseling by the oncology service, the patient decided to only receive palliative pain control and died 2 months after the diagnosis of the tumor-associated AS.

Figure 1: Clinical photographs (a and b), ocular ultrasound (c-e), and ultrabiomicroscopy (f-h) of the left eye. Anterior scleritis was observed in the temporal and inferior quadrants (A, B, black arrow). A possible sentinel vessel is also observed (A, black arrowhead). Choroidal metastases (black asterisk) are visualized in ocular ultrasound in an axial (C) and transversal (D) section. On A-scan, they possessed medium-high reflectivity (E). Through ultrabiomicroscopy, choroidal metastases show marked irregularity in its thickness and height and an internal heterogeneous, diminished echogenicity (F, G, black asterisk). An intrascleral area of hypoechogenicity is also visible (F, black arrow). The ciliary body (G, H, black arrow) and anterior chamber (h) appear unaffected

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Discussion

AS is an unusual presentation of ocular metastases, probably associated with the fact that most of these lesions occur in the posterior pole and not in more anterior regions.^[1] Interestingly, of the available cases in the medical literature, most are associated with lung adenocarcinoma, as in the present case.^[2],[6] The reported prevalence of choroidal metastasis in patients with cancer is 2%–7%.^[1] As in the present patient, the most prominent symptom is unrelenting ocular pain.^[4],[6] A lag time to correct diagnosis and an initial suspicion of an inflammatory pathology is also common.^[3],[4],[6] In addition, the right diagnosis is often provided by imaging studies.^[4],[6] US is especially useful in the location and definition of choroidal metastases, with the classical picture being that of a solid, irregular, acoustically heterogeneous lesion, with high-medium reflectivity on A mode.^[1] In the present case, we used a 20MHz high-frequency probe. Previous authors have documented that the detection and measurement of flat intraocular lesions are enhanced when using a 20 MHz instead of a 10 MHz US probe.^[10] The US characteristics of the choroidal metastases in the present case match those previously reported.^[1] More recently, metastases to the iris and ciliary body have been examined using UBM.^[7],[8] UBM examination of the inferotemporal area revealed a flat, remarkably irregular, and heterogeneously thickened choroid. This image is most reminiscent of a pattern described with enhanced depth imaging optical coherence tomography by Deaner et al.^[6] as “lumpy-bumpy” in another patient with choroidal metastases and unrelenting ocular pain, misdiagnosed as posterior scleritis. The irregularity and heterogeneity of the choroid in these patients could be associated with the uncontrolled tumoral growth or to more than only one seeding site of the metastases. In addition, the focal scleral hypoechogenicity visualized in the UBM [Figure 1] could correspond to an inflammatory exudate or tumoral extension. Pain in choroidal metastases could be related to choroidal and scleral inflammation (due to tumoral necrosis) and infiltration. The exact location of the choroidal infiltration underneath the AS in this patient is probably related to these changes. Therefore, US and UBM evaluation is of utmost utility in patients with suspected ocular metastases, and a topographical correlation between the slit-lamp findings and the underlying pathology is possible and should be actively looked for. Finally, ophthalmologists play an important role in diagnosing active metastasis in oncological patients with apparent remission. A low threshold for suspecting masquerading syndromes in these patients and requesting imaging studies, such as US and UBM, should be maintained.

Acknowledgments

The authors would like to thank Sara Gonzalez Godinez, MD, for her aid in the interpretation and description of the US and ultrabiomicroscopic images.

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

1.	Mathis T, Jardel P, Loria O, Delaunay B, Nguyen AM, Lanza F, et al. New concepts in the diagnosis and management of choroidal metastases. Prog Retin Eye Res 2019;68:144-76.
2.	Chen HF, Wang WX, Li XF, Wu LX, Zhu YC, Du KQ, et al. Eye metastasis in lung adenocarcinoma mimicking anterior scleritis: A case report. World J Clin Cases 2020;8:410-4.
3.	Dotchin S, Lakosha H, Heathcote JG, Dickinson J. Uveal metastasis from testicular choriocarcinoma presenting as scleritis. Can J Ophthalmol 2009;44:210-1.
4.	Lee BJ, Lowder CY, Biscotti C, Schoenfield L, Singh AD. Ciliary body metastasis masquerading as scleritis. Br J Ophthalmol 2007;91:1582, 1649.
5.	Yeo JH, Jakobiec FA, Iwamoto T, Brown R, Harrison W. Metastatic carcinoma masquerading as scleritis. Ophthalmology 1983;90:184-94.
6.	Deaner JD, Pointdujour-Lim R, Say EA, Shields CL. Unrelenting ocular pain as a masquerading symptom of occult choroidal metastasis. Ocul Oncol Pathol 2017;3:56-9.
7.	Hernández-Ayuso I, Rodríguez-Reyes AA, Ríos Y Valles-Valles D, Kawakami-Campos PA, Herrera Cifuentes SL. Just another metastatic carcinoid tumour to the uveal tract. Saudi J Ophthalmol 2018;32:355-7.
8.	Neitzke R, Spraul CW, Lang GE, Lang GK. Iris metastases in breast carcinoma. Ophthalmologe 2001;98:1097-100.
9.	Moura LR, Yang YF, Ayres B, Brasil OM, Fernandes BF, Burnier MN Jr. Clinical, histologic, and immunohistochemical evaluation of iris metastases from small cell lung carcinoma. Can J Ophthalmol 2006;41:775-7.
10.	Albrieux M, Pégourié P, Aptel F, Satger D, Bru M, Zaatar G, et al. Evaluation of 20-MHz high-frequency ultrasonography for the diagnosis of choroidal nevi. Graefes Arch Clin Exp Ophthalmol 2021;259:181-9.