Recurrent Vitreous hemorrhage and retinal vasculitis as the initial presentation of Lung Adenocarcinoma in a middle-aged male

Author: Alejandra Parra-Morales (Spain)

Co-authors: Alvaro Casado, Beatriz Framiñán

Purpose

The purpose of this communication is to report the case of a patient with recurrent vitreous hemorrhage and progressive retinal vasculitis unresponsive to ocular treatment as the initial and unusual presentation of lung adenocarcinoma.

Setting/Venue

Clinical case presented at the Department of Ophthalmology of Salamanca University Hospital Complex, which is a public hospital serving a population of 332.234 with weekly

Methods

Clinical case description as well as a non-systematic literature review.

Results

A 69-year-old man, without relevant disease, presented to our clinic with sudden left eye vision loss, visual acuity (VA) was of 20/63 and vitreous hemorrhage (VH) was diagnosed. Pars plana vitrectomy (PPV) was performed with endolaser over a small peripheral vascular telangiectasia. A month later, he developed an inferior retinal detachment that required surgery; during immediate postoperative period complete hyphema and VH developed, requiring a third intervention that revealed multifocal areas of vasculitis, telangiectasia, pre-retinal white infiltrates, and subretinal hemorrhages. Laser photocoagulation was applied in affected areas; and intravitreal anti-VEGF was injected. However, complete hyphema and VH recurred one day later. Ancillary tests and aqueous/vitreous cultures were negative; nevertheless, chest X-ray revealed cannon-ball metastases from a lung adenocarcinoma primary tumor. Chemotherapy and pro-re-nata (PRN) anti-VEGF treatments were indicated. Later on, fundus examination of the fellow eye showed focal areas of pre/intra/subretinal and mild vitreous hemorrhages. Fluorescein angiography showed areas of early hyperfluorescent telangiectatic vessels consistent with funduscopic lesions and previous findings in the left eye. PRN anti-VEGF along with systemic treatment were indicated for the right eye, with long term clinical stabilization. Left eye VA remained of hand motion due to hemato-cornea.

Conlusions

Retinal vasculitis as first presentation of malignancy has been described in the literature related to paraneoplastic retinopathies (PRs) such as cancer associated retinopathy (CAR) and melanoma associated retinopathy (MAR). There is scarce literature of retinal vasculitis not associated to PRs or ocular metastases as first presentation of lung neoplasms, nevertheless, there are some reports of autoimmune vasculitis as initial presentation of malignancy. Even though cancer-associated retinopathy (CAR) has been widely reported, it is not the only ocular manifestation that can be related to malignancy. We report a case of sudden and recurrent vitreous hemorrhage associated with hyphema and bilateral vasculitis that lead to the diagnosis of lung adenocarcinoma. We state the importance of studying systemic disease and specifically neoplasia in idiopathic cases of vitreous or anterior chamber hemorrhage.

Financial Disclosure

We have no financial disclosure.