The patient was a 62-year-old woman who complained of blurred vision in the right eye for one month. The visual acuity was 20/40 OD and 20/20 OS. On examination, she was found to have an inner retinal white lesion in the temporal juxtafoveal area. There were no hemorrhages, but there was dilation of blood vessels adjacent to the lesion. What is the most likely diagnosis?
The patient had a history of breast cancer diagnosed and treated in 2019. She was recently found to have multiple brain metastases, but there were no other known metastatic lesions. This lesion in the right eye was very likely a retinal metastasis. The lesion was solid and vascularized. The bottom-right OCTA image shows an area of vascularity highlighted with yellow coloration, and there is also disruption of the retinal layers as well as shallow subretinal fluid.
Breast cancer is a leading cause of metastases to the eye, and most lesions are in the choroid. Retinal metastases are very uncommon.1 Metastases to the eye are strongly associated with metastases to the brain. While radiation treatment is very efficacious in preserving vision, the general medical prognosis is guarded. This patient had radiation treatment to the brain planned, and those plans were adjusted to include ocular treatment.
There are other conditions that can resemble the white lesion of this patient. A branch retinal artery occlusion can cause inner retinal whitening, but temporal BRAOs have a distribution that generally respects the horizontal midline and the whitening typically has an arcuate shape. Infectious processes, such as primary toxoplasmosis, have a fuzzier border and are associated with significant vitreous cells in immunocompetent patients. Astrocytic hamartomas can have a similar appearance as our patient’s lesion. Astrocytic hamartomas are initially vascular, and they become calcified over time. They are in the inner retina and present as elevated whitish lesions. They often have a nodular surface resembling a mulberry. They are not be associated with disruption of deeper retinal layers or subretinal fluid.
1. Shields CL, McMahon JF, Atalay HT, Hasanreisoglu M, Shields JA. Retinal metastasis from systemic cancer in 8 cases. JAMA Ophthalmology 2014;132:1303-8.
The patient had a history of breast cancer diagnosed and treated in 2019. She was recently found to have multiple brain metastases, but there were no other known metastatic lesions. This lesion in the right eye was very likely a retinal metastasis. The lesion was solid and vascularized. The bottom-right OCTA image shows an area of vascularity highlighted with yellow coloration, and there is also disruption of the retinal layers as well as shallow subretinal fluid.
Breast cancer is a leading cause of metastases to the eye, and most lesions are in the choroid. Retinal metastases are very uncommon.1 Metastases to the eye are strongly associated with metastases to the brain. While radiation treatment is very efficacious in preserving vision, the general medical prognosis is guarded. This patient had radiation treatment to the brain planned, and those plans were adjusted to include ocular treatment.
There are other conditions that can resemble the white lesion of this patient. A branch retinal artery occlusion can cause inner retinal whitening, but temporal BRAOs have a distribution that generally respects the horizontal midline and the whitening typically has an arcuate shape. Infectious processes, such as primary toxoplasmosis, have a fuzzier border and are associated with significant vitreous cells in immunocompetent patients. Astrocytic hamartomas can have a similar appearance as our patient’s lesion. Astrocytic hamartomas are initially vascular, and they become calcified over time. They are in the inner retina and present as elevated whitish lesions. They often have a nodular surface resembling a mulberry. They are not be associated with disruption of deeper retinal layers or subretinal fluid.
1. Shields CL, McMahon JF, Atalay HT, Hasanreisoglu M, Shields JA. Retinal metastasis from systemic cancer in 8 cases. JAMA Ophthalmology 2014;132:1303-8.
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