|Year : 2021 | Volume
| Issue : 2 | Page : 202-204
Bilateral metastasis to optic nerve head – Interesting case report series
Isha Agarwalla, Dipankar Das, Harsha Bhattacharjee, Ganesh Kuri, Bhavya Mehta, Mohit Garg, Anand Bhosale
Sri Sankaradeva Netralaya, Guwahati, Assam, India
|Date of Submission||09-Apr-2020|
|Date of Decision||22-Jun-2020|
|Date of Acceptance||20-Jul-2020|
|Date of Web Publication||24-Jun-2021|
Dr. Isha Agarwalla
Sri Sankaradeva Netralaya, Beltola, Guwahati, Assam
Source of Support: None, Conflict of Interest: None
Most intraocular metastatic tumors occur in the uveal tract, while isolated metastasis to the optic nerve is rarely found. Breast and lung cancers are the tumor types metastasizing to the eye most frequently; however, metastases of prostate cancer, melanoma, gastrointestinal tract, and renal tumors have also been reported. We describe three rare cases of optic nerve metastasis from primary carcinoma in brain, bone, and ano-rectum, which were not found in the literature previously. Bilateral optic disc edema in a patient with primary tumor elsewhere should be evaluated completely to rule out metastasis.
Keywords: Bilateral disc edema, metastasis, optic nerve
|How to cite this article:|
Agarwalla I, Das D, Bhattacharjee H, Kuri G, Mehta B, Garg M, Bhosale A. Bilateral metastasis to optic nerve head – Interesting case report series. TNOA J Ophthalmic Sci Res 2021;59:202-4
|How to cite this URL:|
Agarwalla I, Das D, Bhattacharjee H, Kuri G, Mehta B, Garg M, Bhosale A. Bilateral metastasis to optic nerve head – Interesting case report series. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Jul 27];59:202-4. Available from: https://www.tnoajosr.com/text.asp?2021/59/2/202/319254
| Introduction|| |
Although many cases of ocular malignant tumor metastases involving the uveal tract have been reported, particularly the posterior temporal choroid, secondaries to the optic disc is very rare. Shields et al. reported only eight cases of isolated optic nerve metastasis without retinal or choroidal involvement in a series of 660 patients with intraocular metastasis. Ferry and Font in a series of 227 patients with ocular metastasis, orbital metastasis, or both, reported that only three cases (1.3%) involved metastases to the optic nerve or optic nerve sheath.
We report three rare cases of optic nerve metastasis from the brain, bone, and rectum.
| Case Reports|| |
A 60-year-old presented to our institution complaining of dimness of vision in both eyes with headache for the past 1 year. There was no history of trauma. The patient was a known diabetic for the past 7 years.
On physical examination, cervical lymphadenopathy was noted. Ocular examination revealed normal alignment and visual acuity (6/12; N8) in both eyes. Slit-lamp anterior segment biomicroscopy was unremarkable. On dilated fundus examination, infiltrating optic disc edema [Figure 1]b and [Figure 1]c was seen bilaterally.
|Figure 1: (a) Computed tomography scan of the brain and orbit showing heterogeneous peripheral enhancing lesions left occipital region with perifocal edema; (b and c) Bilateral infiltrating optic disc edema|
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Computed tomography (CT) scan of the brain and orbit revealed multiple heterogeneous peripheral-enhancing lesions of varying sizes in bilateral frontoparietal and left occipital region with perifocal edema and mass effect with mild midline shift toward left suggestive of metastatic lesion [Figure 1]a. For further management for the primary tumor of the brain patient was referred to an oncologist.
A 29-year-old male, who was diagnosed with osteosarcoma (2 months back), sought treatment for the gradual loss of vision with headache and vomiting for the last 1 month. Contrast-enhanced magnetic resonance imaging (MRI) of the left wrist and hand, done at the time of her diagnosis revealed an infiltrating lesion in epi-metaphyseal region of the distal end of left radius appearing hypointense on T1- and T2-weighted images, showing wide zone of transition, permeative destruction, postcontrast heterogeneous enhancement with associated periosteal reaction and large periosteal soft-tissue component suggesting of neoplastic changes. To rule out metastasis elsewhere, a bone scan was performed and metastatic changes were found in C3 and D3 vertebra and 3rd rib [Figure 2]a. At presentation, the symptoms had progressed to no light perception in both eyes. On slit-lamp anterior segment was unremarkable with sluggishly reacting pupil. Papilloedema was seen on fundus examination in both eyes [Figure 2]b and [Figure 2]b and c.
|Figure 2: (a) Bone scan done revealing no metastasis elsewhere; (b and c) Papilledema was seen on fundus photo in both eyes|
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A 43-year-old male patient was diagnosed with anorectal carcinoma 10 months ago and confirmed by colonoscopy and contrast-enhanced CT whole abdomen that revealed circumferential irregular wall thickening of distal rectum and anal canal with mildly enlarged nodes in the perirectal and inferior mesenteric region [Figure 3]a. Biopsy of the lesion reported adenocarcinoma. The patient underwent preoperative external-beam radiotherapy with 6 MV photons, a total dose of 45 Gy in 25 fractions along with chemotherapy with capecitabine. Two months later, abdominal and perianal resection was done along with end colostomy. The patient received six cycles of postoperative polychemotherapy.
|Figure 3: (a) Computed tomography of the whole abdomen that revealed circumferential irregular wall thickening of distal rectum and anal canal with mildly enlarged nodes in the perirectal and inferior mesenteric region; (b and c) Magnetic resonance imaging of the brain and orbit showing diffusely thickened optic nerve with dense heterogeneous enhancement of the nerve as well as cerebrospinal fluid sheath on either side (L > R) associated with peri.optic soft.tissue standings suggestive of metastasis; (d and e) dilated fundus examination showing papilledema in both eyes|
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The patient presented to us with sudden painless dimness of vision in both eyes and headache for last 6 days. Vision dropped down to counting finger close to face in the RE and hand movement in the LE. Dilated fundus examination revealed papilloedema in both eyes [Figure 3]d and [Figure 3]e. MRI of the brain and orbit was advised to locate the metastatic foci.
MRI of the brain and orbit showed diffusely thickened optic disc with T2 hypointense signal, dense heterogeneous enhancement of the nerve as well as cerebrospinal fluid sheath on either side (L > R) associated with peri-optic soft-tissue standings suggestive of metastasis [Figure 3]b and [Figure 3]c. Subsequently, he was referred to oncologist for further management.
| Discussion|| |
Most previously reported cases with metastatic optic nerve tumors showed choroidal invasion,, while a few have been reported without evidence of choroidal lesions. Isolated metastasis to the optic disc is extremely rare, with a reported incidence among intraocular metastases ranging from 1.2% to 4%. Optic disc metastasis is usually characterized by central swelling of hemorrhage in the disc, with 84% of reported cases appearing as diffuse enlargement of the optic disc without a distinct nodule and similar features were noted in our cases.
In our study and literature review, we included the case series of patients with an ophthalmoscopically visible swelling of the optic disc and with circumstances strongly indicative of metastasis from a distant organ. As the prime focus was to look for the optic nerve involvement, no cases without disc involvement were reviewed.
Previous studies reported optic nerve metastasis from breast, lung, and prostate, pancreas, intestine, thyroid, larynx,,,,, and cutaneous melanoma. We did not find any previous cases of proven rectal adenocarcinoma, brain metastasis, or osteosarcoma of bone metastasis to optic nerve in the literature even when the adjacent choroid was included.
Differential diagnoses from a secondary optic disc tumor include lesions that may cause elevation of the optic disc, such as congenital nonneoplastic lesions, primary optic nerve tumors, myelinated nerve fibers, nongranulomatous and granulomatous papillitis, optic disc drusen, and papilledema, as well as others. Since each has different ophthalmic and systemic significance, it is necessary for the ophthalmologist to recognize them and to plan strategically the management of management with additive precautions. These all fall under the categories of pseudotumor of the disc.
The various congenital lesions, congenital pit of disc, myelinated nerve fibers, and coloboma are unilateral, but may occur bilaterally as well. Optic disc pit occurs as a gray crater temporally, maybe confused with melanocytoma. Coloboma of the disc is a depressed lesion, but due to leucocoria may mimic retinoblastoma. Morning glory syndrome with a central crater of fibroglial tissue may lead to confusion with neoplasm. Several inflammatory lesions may cause this appearance of the disc that includes granulomatous and nongranulomatous inflammation.
Noninflammatory, nontumourous optic disc drusen appear as calcified substances and may occur like astrocytic hamartoma in some instances. Compressive papillopathy can occur due to compression of the optic nerve due to thyroid and pseudotumor. They cause blurred disc margins with dilated, tortous vessels. Finally, papilledema causes bilateral elevation of the disc with blurred disc margins and obliterated cup. Hemorrhages and exudation occur with advanced stages.
In an article by Kyun et al., optic nerve metastasis of breast carcinoma was initially misdiagnosed as a retrobulbar optic neuritis and was later confirmed to be a case of optic nerve metastasis, thus warranting us that previously undiagonosed cancerous cases can be missed by the nonspecific ocular findings.
Furthermore, in a report by Fox et al., optic nerve metastasis mimicked optic nerve meningioma, by its indolent pattern of growth and similar radiographic imaging, thus warranting a clear and thorough systemic review of the patient presenting with any nonspecific fundus findings.
Thus, there can be many lesions that can present as an elevation of the optic disc. Since each of them has specific ophthalmic and systemic significance, it is important to recognize them and to plan strategically the management. Important inflammatory and benign congenital conditions should be differentiated from malignant neoplasms that can cause an elevation of the optic disc.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shields CL, Shields JA, Gross NE, Schwartz GP, Lally SE. Survey of 520 eyes with uveal metastases. Ophthalmology 1997;104:1265-76.
Fox B, Pacheco P, DeMonte F. Carcinoma of the breast metastatic to the optic nerve mimicking an optic nerve sheath meningioma: Case report and review of the literature. Skull Base 2005;15:281-7.
Shields JA, Shields CL, Singh AD. Metastatic neoplasms in the optic disc: The 1999 Bjerrum Lecture: Part 2. Arch Ophthalmol (Chicago,Ill : 1960) 2000;118:217-24.
Ferry AP, Font RL. Carcinoma metastatic to the eye and orbit: A clinicopathological study of 227 cases. Arch Ophthalmol 1974;92:276-86.
Christmas NJ, Mead MD, Richardson EP, Albert DM. Secondary optic nerve tumors. Surv Ophthalmol 1991;36:196-206.
Fukuda R, Tanabe T, Sawamura H, Kawata M, Tsuji H, Kaburaki T. Case of metastatic pulmonary carcinoma in optic disc diagnosed from results of biopsy performed during vitrectomy surgery. Graefes Arch Clin Exp Ophthalmol 2011;249:1883-7.
Zappia RJ, Smith ME, Gay AJ. Prostatic carcinoma metastatic to optic nerve and choroid. Association with changes resembling papilledema. Arch Ophthalmol 1972;87:642-5.
Ring HG. Pancreatic carcinoma with metastasis to the optic nerve. Arch Ophthalmol 1967;77:798-800.
Yildiz I, Sen F, Tuncer S, Kilic L, Basaran M, Bavbek S. Optic disc and choroidal metastasis from sporadic medullary thyroid carcinoma: Case report and review of the literature. Onkologie 2011;34:630-3.
Adachi N, Tsuyama Y, Mizota A, Fujimoto N, Suehiro S, Adachi-Usami E. Optic disc metastasis presenting as an initial sign of recurrence of adenoid cystic carcinoma of the larynx. Eye (Lond) 2003;17:270-2.
Cho HK, Park SH, Shin SY. Isolated optic nerve metastasis of breast cancer initially mimicking retrobulbar optic neuritis. Eur J Ophthalmol. 2011:513-5. doi: 10.5301/EJO.2010.6099. PMID: 21140366.
[Figure 1], [Figure 2], [Figure 3]