Discussion

Ocular neoplasm may be a primary or secondary. The secondaries are far more common than the primary neoplasm.[2] The choroid is the highly vascular layer of the eye and thus the most common site for homing of the malignant cells although the retina and ciliary body can also be involved. Even in the malignancies where ocular metastasis is common such as carcinoma breast, carcinoma lung, and carcinoma of gastrointestinal tract, the first sites of metastasis are the lungs, brain, bones, and liver before the eyes being affected. Development of ocular secondary without involvement of all these sites is rare, and development of ocular metastasis without development of brain metastasis is even rarer.[2]

Unilateral choroidal metastasis is more common than bilateral metastasis.[3] Some studies have indicated that metastatic disease is more common in the left eye as the left common carotid ascends directly off the aorta; tumor cells from the circulation could have a more direct path to left orbit. Diagnosing the disease is often challenging. Retinal detachment, intravitreal, and subretinal hemorrhage are the common complications of choroidal metastasis. Retinal detachment gives rise to visual loss which is very common in these cases.[4]

Ultrasonography shows diffuse choroidal thickening with high or medium amplitude echoes and may mimic choroidal melanoma which is an important differential diagnosis. USG can provide an idea about the local extent of the mass but cannot differentiate between a primary and metastasis.

Clinical profile, MRI, and fludeoxyglucose PET CT can help in differentiating this condition from the common differential diagnoses, for example, choroidal melanoma and hemangioma, although none of these investigations are diagnostic. The treatment options after diagnosis of distant metastasis are very limited and depend mainly upon the distant site of metastasis. The treatment is mainly palliative with the aim of symptomatic relief.

Palliative radiotherapy can be delivered for pain or proptosis. It may improve symptoms in 80% of patients but may or may not restore vision. Chemotherapy for systemic disease can help to control ocular metastasis. The most active chemotherapeutic agents in metastatic head and neck cancers are platin, taxanes, 5-fluorouracil, and cetuximab.[5],[6],[7],[8] Palliative surgery comes into play for intractable ocular morbidities such as proptosis and pain which need urgent intervention. Hormone therapy can help in hormone-sensitive tumor like carcinoma breast.[9] Patient's performance status, life expectancy, status of the primary tumor, and possible side effects of the intended treatment determines the line of management. The overall prognosis for such patients remains poor.[10] However, when the primary disease is under control and eye is the only metastatic site, as in this case, or in carcinoma breast patients, where overall survival has improved dramatically in recent times, the search of some novel targeted treatment, new investigational agents, and advances in radiotherapy techniques may lead to better quality of life and preservation of ocular function.

Conclusion

Although ocular metastasis is not common in head and neck cancer, any patient having visual complaints should be thoroughly investigated. In rare instances, it can also be the first manifestation of an underlying undiagnosed malignancy. Although it is difficult to cure, early diagnosis can lead to prompt interventions which can lessen the suffering of the patient and restore or preserve the remaining visual function.

Conflict of Interest

There are no conflicts of interest.

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Publication History

Article published online:
17 June 2021

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