A case of choroidal mass and dementia: from the local finding to the systemic diagnosis.

Author: María Victoria Segura Fernández-Nogueras (Spain)

Co-authors: Juan Marín Nieto, Juan Yanguas Lucena, Navin Rachwani Parshotam, Szymon Gluszko, Esperanza Ramírez Moreno, Adrían Robles García

Purpose

The most frequent malignant tumor of the eye in adults is uveal metastasis. About 35% of times a choroidal mass is found, the primary tumor is unknown which means that the choroidal mass is the first sign of a malignant systemic neoplasm. Our purpose is to report a case of choroidal mass as the first sign of a malignant systemic neoplasm in a patient with vitamin B12 deficiency dementia making the management and treatment harder due to the lack of concern of their own pathology.

Setting/Venue

Department of Ophthalmology in a tertiary level hospital of Spain.

Methods

A case report. We present a 60-year-old Caucasian woman who attended the Emergency Room of Ophthalmology due to blurry vision in her right eye (RE). The best corrected visual acuity was hand movements (LogMAR > 1) in RE and 20/20 in the left eye (LE). No pathological findings were observed in the anterior segment and the intraocular pressure (IOP) was 15mmHg. The RE fundus examination revealed the presence of two choroidal masses with an exudative retinal detachment associated. According to the anamnesis the patient was not diagnosed with cancer; so she was informed about the potential severity of those findings and the need of ruling out a malignant neoplasm. Surprisingly, the patient showed indifference and seemed to be alien to this new situation, not attending any appointments with the Oncology and Radiology departments. It was not after contacting the patient's General Practitioner to make them aware of the patient’s behaviour that a vitamin B-12 deficiency dementia was diagnosed. Once the treatment for this condition was started, the patient got concerned about the importance of this pathology and started to attend their appointments.

Results

Computerized tomography showed a primary tumor placed in the right breast and disseminated metastatic disease affecting brain, bones, pleura, lungs, and adrenal gland and the blood tests demonstrated malnutrition and low levels of vitamin B12. The patient underwent holocraneal radiotherapy as well as oral chemotherapy with letrozol and ribociclib and she experienced a great systemic improvement. During nine months of follow up in the Department of ophthalmology we have noticed a reduction of choroidal metastases size and the absence of perilesional subretinal fluid. The BCVA is now 20/200 (LogMAR = 1).

Conlusions

When a choroidal metastasis is found the subjacent neoplasm is a breast tumor 50% of times; but unlike this case, most of them have been already diagnosed. The development of a choroidal metastatic disease implies poor vital prognosis and the need of a prompt evaluation and management of the systemic neoplasm by a multidisciplinary team. A strange behavior in patients with this consuming disease is another sign to consider, since it may be dementia due to a poor nutritional condition. As ophthalmologists we must be able to find and recognize a choroidal malignant tumor and other clinical features involving the disease since sometimes we are the first ones facing cancer in the patient.

Financial Disclosure

None.

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