Choroidal metastasis as the initial manifestation of lung carcinoma

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A 65-year-old Indian male presented with complaints of painless diminution of vision (DOV) of the left eye for the past 1 month. There was no history of trauma, floaters, or flashes. He was on medication for diabetes mellitus, hypertension, and benign prostate hypertrophy. There was a history of around 10 kg of weight loss within the last 6 months. There was no history of smoking or tobacco consumption. His best corrected visual acuity was 20/20, N6 in the right eye and 20/80, N10 in the left eye. Intraocular pressures and anterior segment findings were normal. Fundus examination of right eye revealed a few microaneurysms [Figure 1a] and left eye revealed a yellowish-orange choroidal mass measuring about 3 disc diameters beneath the inferotemporal arcade, encroaching on the macula with overlying retinal pigment epithelium (RPE) alterations and inferior exudative retinal detachments (RD) [Figure 1b]. Ultrasound B scan of the left eye revealed a retinochoroidal mass (8.22 mm × 9.82 mm × 3.42 mm) with moderate surface reflectivity and homogeneous internal reflectivity, associated with RD and positive shifting fluid sign.Figure 1: Ultrawide field imaging of (a) The right eye fundus showing few microaneurysms (b) The left eye fundus showing a yellowish-orange choroidal mass beneath the inferotemporal arcade encroaching on the macula (blue arrow) and inferior exudative retinal detachments (orange arrows) (c) Spectralis domain-optical coherence tomography of the left eye showing a dome-shaped “lumpy bumpy” elevation of the neurosensory retina and retinal pigment epithelium (green arrow) with associated neurosensory retinal detachment (yellow arrow)Spectralis domain-optical coherence tomography revealed a dome-shaped “lumpy bumpy” elevation of the neurosensory retina and RPE with associated neurosensory detachment [Figure 1c] involving the fovea. Based on the above findings, a diagnosis of choroidal metastasis was made, and a whole-body positron emission tomography-computed tomography (PET-CT) scan was advised. PET-CT showed metabolically active, heterogeneously-enhancing, irregular pleural soft-tissue mass-lesion in upper lobe of the left lung along with multiple pleuroparenchymal soft-tissue lesions of varying sizes. Multiple enlarged lymph nodes and skeletal metastases were noted. The patient was sent for oncology referral on an urgent basis. The choroid is the most common ophthalmic site for metastatic disease.[1] Choroidal metastasis tends to become apparent late in the course of malignancy and has a poor prognosis. Breast carcinoma is the most common primary site followed by lung cancer.[1] Lung cancer presenting with choroidal metastasis as the initial sign is rare with roughly 60 such cases published in literature till date.[2-6] The present case highlights the importance of careful and meticulous fundus examination in all cases with or without DOV, as many small choroidal lesions can be missed on cursory examination. 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.

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