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SHORT COMMUNICATION
Year : 2021  |  Volume : 59  |  Issue : 4  |  Page : 425-426

Unilateral iris nodules with neovascular glaucoma: A window to widespread systemic metastasis of primary breast carcinoma


1 Department of Glaucoma, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
2 Department of Retina and Vitreoretinal Surgery, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Submission23-Aug-2020
Date of Decision30-Jun-2021
Date of Acceptance02-Jul-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Dr. Vijayalakshmi A Senthilkumar
Department of Glaucoma, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, 1.Anna Nagar, Madurai - 625 020, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_120_20

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How to cite this article:
Senthilkumar VA, Raj P, Mishra C. Unilateral iris nodules with neovascular glaucoma: A window to widespread systemic metastasis of primary breast carcinoma. TNOA J Ophthalmic Sci Res 2021;59:425-6

How to cite this URL:
Senthilkumar VA, Raj P, Mishra C. Unilateral iris nodules with neovascular glaucoma: A window to widespread systemic metastasis of primary breast carcinoma. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2022 Aug 12];59:425-6. Available from: https://www.tnoajosr.com/text.asp?2021/59/4/425/333155



We report a rare presentation of systemic metastasis of a primary breast carcinoma masquerading as unilateral anterior uveitis with neovascular glaucoma (NVG). Metastasis to the iris is uncommon; however once detected, it is associated with a median time to survival of 10 months only.[1] Hence, diagnosing it at an early stage would enable us to prolong the life expectancy in such individuals.

A 33-year-old female presented with defective vision and redness in the right eye (RE), for 4 months. Best-corrected-visual-acuity and intraocular pressure (IOP) in the RE were 20/200 and 60 mmHg, respectively. Detailed examination revealed circumcorneal congestion, multiple tan-colored iris stromal lesions, cells 2+ (standardization of uveitis nomenclature group grading system), and 360° active iris neovascularization [Figure 1]a and [Figure 1]b. Fundus examination RE revealed a cup-disc-ratio of 0.8. Fundus fluorescein angiography (FFA) RE revealed patchy hyperfluorescence in the posterior pole and in the periphery, and optical coherence tomography revealed that macula was normal [Figure 2]a and [Figure 2]b. Other eye findings (LE) were unremarkable [Figure 2]c and [Figure 2]d. Our patient underwent detailed systemic evaluation such as computed tomography (CT) of the chest, Ultrasonogram (USG) of the abdomen, and microbiological examination for HIV and tuberculosis, and Treponema pallidum hemagglutination assay. However, CT imaging demonstrated widespread metastasis involving sternum, vertebra, liver, lung, and pleura [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. On further probing, she gave a history of left-sided breast carcinoma for which radical mastectomy was performed 3 years ago. A clinical diagnosis of iris metastasis with NVG, anterior uveitis, and presumed choroidal metastasis secondary to breast carcinoma with widespread systemic metastasis was made. In the FFA, we noticed patchy irregular hyperfluorescence anterior to the vascular arcade and along the equator, which we presumed to be choroidal metastasis.
Figure 1: (a) Slit-lamp photograph of the right eye showing circumcorneal congestion, multiple tan-colored small elevated lesions on iris surface with irregular margins (white arrowheads) suggestive of iris metastasis, nonreacting 7 mm mid dilated pupil and cataractous lens and neovascularization of iris (black arrowhead). (b) Magnified view of iris nodules

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Figure 2: (a) Fundus fluorescein angiography of the right eye revealed patchy irregular hyperfluorescence anterior to the vascular arcade and along the equator. (b) Normal optical coherence tomography of the right eye. (c and d) Fundus fluorescein angiography and optical coherence tomography of the left eye were unremarkable except for central serous chorioretinopathy

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Figure 3: (Multislice spiral computed tomography volume scan of the chest): (a) Pleural effusion in the right lung (b) Destructive lesions noted in the vertebral column (C6 and L2 levels) and sternum (arrow marks). (c) Multiple secondaries in both lungs' parenchyma. (d) Nodule in the anterior chest wall in the left side over the area of mastectomy (white arrow)

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The Patient was started on maximal ocular hypotensive medications along with topical steroids (prednisolone acetate 1%) and cycloplegics (atropine 1%). She was referred to an oncologist for systemic chemotherapy and the patient underwent partial diode laser cyclophotocoagulation for controlling IOP followed by palliative therapy with intravitreal bevacizumab 1.25 mg/cc for regression of new vessels.

Metastasis to the anterior uvea is very rare compared with choroidal metastasis.[2] Breast cancer (68%) is the most common cause of iris metastasis, followed by lung cancer (40%) and cutaneous melanoma.[1] Current treatments for iris metastasis include systemic chemotherapy, iridectomy, focal plaque radiotherapy, external beam radiation or enucleation, and intravitreal bevacizumab injection.[1],[2],[3]

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.

Acknowledgment

We would like to thank Mr. Rajkumar, Photographer, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shields CL, Kaliki S, Crabtree GS, Peshtani A, Morton S, Anand RA, et al. Iris metastasis from systemic cancer in 104 patients: The 2014 Jerry a. Shields Lecture. Cornea 2015;34:42-8.  Back to cited text no. 1
    
2.
Seidman CJ, Finger PT, Silverman JS, Oratz R. Intravitreal bevacizumab in the management of breast cancer iris metastasis. Retin Cases Brief Rep 2017;11:47-50.  Back to cited text no. 2
    
3.
Makri OE, Psachoulia C, Exarchou A, Georgakopoulos CD. Intravitreal ranibizumab as palliative therapy for iris metastasis complicated with refractory secondary glaucoma. J Glaucoma 2016;25:e53-5.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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