C A S E R E P O R T

Chest Radiographs in Uveitis Patients

YAP YEW CHONG, MBBS, MRCS(OPHTH),

VIKAS SHARMA, MD, MRCSED(OPHTH),

N. RAJA, FRCSED(OPHTH), FRCOPHTH,

S. KODATI, FRCSED(OPHTH), FRCOPHTH

A B S T R A C T

This is an article regarding a patient presented with bilateraluveitis who was subsequently found to have lung carcinomaon further investigations. We recommend doing a CXRespecially in uveitis patients who have a history of smoking.

INTRODUCTION

Most uveitis cases seen are idiopathic and are not

investigated. Our patient presented with bilateral

uveitis and had previously smoked for more than

45 years. Apart from uveitis he had no other symp-

toms. A chest radiograph was suggestive of lung

carcinoma and fine-needle aspiration biopsy showed

squamous cell carcinoma.

CASE REPORT

An 83-year-old gentleman was referred from the

general practitioner with a first episode of right eye

visual blurring for 1 week. His past medical history

included hypertension, hypercholesterolemia, and

aortic and mitral valve diseases. He was an ex-smoker

with a 45-pack year and worked as an engineer

machinist but with no obvious industrial exposure.

On examination, his visual acuity was VR CF closely

and VL 6/12–6/9 (pinhole correction). He was found

to have bilateral uveitis with cells 2+ flare. There

were fine keratic precipitates on the endothelium of

both corneas. Intraocular pressures were normal.

However there were no iris or ciliary body nodules

and no posterior or peripheral anterior synechiae.

Fundal examination showed wet age macula degen-

eration changes on the right posterior pole and dry

age related macula degeneration on the left fundus. In

view of the severity of his uveitis, investigations were

ordered, including complete blood count (CBC),

erythrocyte sedimentation rate (ESR), rheumatoid

factor (RF), and chest and sacroiliac radiographs. He

was also treated with G Pred forte four times a day.

The uveitis responded to steroid therapy and the

anterior chamber had 1+ cells 1 week later. A follow

R E P R I N T SYap Yew Chong, MBBS, MRCS(ophth), Department of OphthalmologyWatford

General Hospital, Watford, Herts WD18 0HB, UK. E-mail: eyapyc@gmail.com.

Dr. Yap YC, Sharma, Raja, and Kodati are with the Department of Ophthal-

mology, at Watford General Hospital, Watford, Herts, United Kingdom.

The authors have stated that they do not have a significant financial interest or

other relationship with any product manufacturer or provider of services dis-

cussed in this article. The authors also do not discuss the use of off-label

products, which includes unlabeled, unapproved, or investigative products or

devices.

The authors present a case of bilateral uveitis in whom a chest radiograph was

suggestive of a lung carcinoma and fine needle aspiration biopsy showed

squamous cell carcinoma. They recommend chest radiography in uveitis pa-

tients with a history of smoking.

Submitted for publication: 2/15/07. Accepted: 3/27/07.

Annals of Ophthalmology, vol. 39, no. 3, Fall 2007

� Copyright 2007 by ASCO

All rights of any nature whatsoever reserved.

1530-4086/07/39:267–269/$30.00. ISSN 1558-9951 (Online)

ANN OPHTHALMOL. 2007;39 (3) ..............................................267

up appointment was arranged for treatment of his

age-related macula degeneration but fundal fluores-

cein angiography showed that he would not benefit

from photodynamic therapy.

Chest radiograph showed a lobulated 4.5 cm mass

above the right hilum representing a pulmonary

neoplasm (Fig. 1). Computed axial tomography (CT)

of the thorax was ordered and showed a 6 cm� 4 cm

well-defined lobulated mass at the apex of the right

lung medially which appeared to be surrounding the

superior vena cava and ascending aorta (Fig. 2).

There was possible tumor extension to the superior

vena cava. A few enlarged nodes were seen at the

pretracheal region. There was no liver metastasis.

An anterior chamber tap was done on this patient

after treatment was instituted but no cells were de-

tected from cytology. He was seen by the respiratory

consultant who arranged a fibreoptic bronchoscopy

and a staging CT scan. Histology result from the lung

biopsy revealed squamous cell carcinoma.

DISCUSSION

A four-year old study conducted to show the efficiency

of radiographic screening for detection of sarcoidosis

and anklylosing spondylitis concluded that radiolog-

ical investigations were not useful in the management

of uveitis patients (1). Data from the Cochrane

Database (based on seven trials, six randomized con-

trolled and one non-randomized controlled trial) did

not support screening for lung cancer with chest

radiography or sputum cytology. In fact, frequent

screening with chest radiography might be harmful

and has a 11% relative increase in mortality from lung

cancer compared with less frequent screening (relative

risk = 1.11; 95% CI: 1.00–1.23) (2).

One study confirmed the usefulness of CT scan of

the thorax in elderly female patients who have idio-

pathic chronic uveitis and of which the majority have

normal chest radiographs. Seventy-six percent of

patients with pathology on CT thorax were later

found to have sarcoidosis on biopsy (3).

Fifty percent of patients with anterior uveitis have

related systemic diseases and common associations

include seronegative arthropathies, sarcodosis,

Bechet’s, syphilis, and tuberculosis (4). Common

causes of uveitis with lung-related disorders include

sarcoidosis, connective tissue diseases, for example

Wegener’s granulomatosis, and systemic lupus eryt-

hematosis (5). Lung cancer causing ocular metastasis

has been reported and is not uncommon. However,

metastasis with uveitis as the presenting feature

without any other systemic manifestations has been

documented in a few cases. Tumor metastasis to the

anterior segment is less common than involvement of

the posterior segment. A retrospective review of 420

patients with 950 uveal metastases over a 20-year

Figure 1—Chest X-rays showing the lesion in the right hilum. Comparison of the two X-rays reveals the increase in size of thelesion in the right lung field since the first CXR was taken 4 years ago.

Figure 2—CT of the thorax with right hilar mass measuring 6by 4 cm.

ANN OPHTHALMOL. 2007;39 (3) ..............................................268

period showed that uveal involvement included the iris

in 90 (9%), ciliary body in 22 (2%), and choroids in 838

(88%). There is a history of a primary cancer in 278

patients (66%) and 142 patients (34%) had no history

of cancer. More than two-thirds of the primary tumor

sites are located at the breast and lung (6).

Approximately 10% of metastasis to the eye in-

volved the anterior segment and patients with anterior

segment metastasis have poorer prognosis and sur-

vival rate than those at the posterior segment or orbit.

In a study of 141 eyes (112 patients) with metastases to

the eye or orbit, lung carcinoma metastasizes earlier

than breast cancer, 276 days compared with 1,266,

and has a shorter median survival time (MST) (188 vs.

666 days) (7). Another study gave a similar median

survival of 5.4 months after surgery in 26 out of 227

patients with metastasis to the anterior segment. Signs

and symptoms produced by the metastatic tumors

involving the anterior segment included decreased

vision (80%), a visible mass (72%), redness of the eye

(56%), glaucoma (56%), iridocylitis (44%), and

hyphema (24%) (8).

There are hypotheses on the causes of anterior

uveitis in patients with ocular metastasis. It may be

due to a systemic inflammatory response as a gener-

alized immune response or it could be due to intra-

ocular metastatic deposits as in neoplastic masquerade

syndrome. Shed tumor cells resembled inflammatory

cells and areas of spontaneous necrosis in tumors

produce inflammatory reaction (9).

No cells were detected in our cytological analysis of

anterior chamber tap. Studies by Woog (10) showed

that a cellular reaction of 3+ is needed to interpret

cytology findings. A negative cytology result on

aqueous does not exclude intraocular malignancy and

it is recommended for other diagnostic evaluations

for example serological markers, immunoperoxidase

staining, and tumor markers of aqueous humor or

vitreous fluids. Fine-needle aspiration biopsy of iris or

ciliary body lesions should be considered. Vitreous

aspiration needle tap may be indicated and this has

been shown to be diagnostic in some patients (11).

More invasive techniques were not done for our

patient in view of his age and because he responded to

topical steroids treatment.

A screening chest radiograph is an invaluable tool

in establishing a diagnosis in patients with uveitis.

Ophthalmologists must be aware that lung pathology

can be a cause of anterior segment inflammation.

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