grand rounds october 20, 2006 jeffrey d. colburn, m.d., pgy-2 vanderbilt eye institute
TRANSCRIPT
Grand RoundsGrand RoundsOctober 20, 2006October 20, 2006
Jeffrey D. Colburn, M.D., PGY-2Jeffrey D. Colburn, M.D., PGY-2
Vanderbilt Eye InstituteVanderbilt Eye Institute
The Case…The Case…• CC: Right eye swelling x 3 weeks
• HPI: 47 y.o. AA male, recently released from jail– “Pressure” in right temple region– Blurry vision, redness & tearing OD– Denies any injuries– Outside ophthalmologist and ENT treating for
sinusitis. Thyroid studies pending.
HistoryHistory• Past Ocular Hx
Negative
• Past Med/Surg HxNegative
• MedsLevaquin, Nasacort HQ,
Prednisone
• Allergies: NKDA
• Family HxAn aunt with Glaucoma
• Social Hx– “pretty good amount” EtOH– 60 pack yr smoking hx– Smokes crack cocaine– Occasional MJN
• ROS+ SOB, fatigue, weakness,
dizziness, HA’s, ~ 20 lbs wt loss, Right ear fullness, lightheadedness,
- Fever, chills, night sweats, URI symptoms,
ExamExam• VA: 20/60 OD, 20/25 OS• IOP: 26 OD, 21 OS • CVF: Full• Pupils: No anisocoria, no RAPD• Motility: OD -3 in upgaze/downgaze, -2 left/right gaze
• Hertel: 25 OD, 18 OS (123mm)• Color: 6/15 OD, 13/15 OS
• External: Proptosis, ptosis & lid edema OD, – No bruit heard over orbit
ExamExam• SLE (OS quiet)
LLL: lids edematous
Conj: arterialized injection, engorged fornix vein
K: arcus OU, otherwise clear
A/C: Deep & Quiet, no C/F
Iris: Intact
Lens: clear
Ant Vit: quiet
ExamExam• DFE:
Disks: sharp margins, good color OU
C/D: 0.6 OD, 0.4 OS
Macula: CWS temporally OD
Periphery: few chorio-retinal scars OS
Vitreous: clear OU
Vascular: mild tortuosity OU
Differential DiagnosisDifferential Diagnosis
Differential DiagnosisDifferential Diagnosis• Vascular
– C-C fistula (Low flow)– Arteriovenous malformation– Cavernous sinus thrombosis
• Neoplastic– Lymphoma/Leukemia– Cavernous sinus tumors– Orbital tumors– Metastatic tumors– Mucocele
• Infectious– Orbital cellulitis– Mucormycosis– Tuberculosis
• Trauma– Retrobulbar hemorrhage– Intraorbital foreign body
• Inflammatory/Infiltrative– Thyroid eye disease– Orbital inflammatory pseudotumor– Orbital vasculitis
• Wegener’s granulomatosis• Polyarteritis nodosa
– Intracranial sarcoidosis– Tolosa-Hunt syndrome
• Neurologic– Cranial nerve palsy
MRIMRI
• Admitted for WBC’s, hyperkalemia, alkalosis
• Labs unrevealing – (RPR, HIV, ANA, thyroid panel, blood cx)
• CXR: vertebral osteoblastic lesions, +lymphadenopathy, reticulonodular opacities
• CT – Diffuse pathologic lymphadenopathy
• Biopsies – poorly differentiated carcinoma
• GI Work-up / Tumor markers – Negative
Diagnosis:Diagnosis:Metastatic Carcinoma of Metastatic Carcinoma of
Unknown PrimaryUnknown Primary
Difficult CourseDifficult Course
• Progression clinically – High IOP despite lateral cantholysis, MMT
• Partial response to IV steroids
• Responded to XRT to right orbit
• Died 5 weeks after presentation– Had completed 1 round of chemotherapy
Metastatic carcinoma to the orbitMetastatic carcinoma to the orbit• Commonly develop symptoms abruptly
• Features:– Pronounced restriction– Eyelid swelling, ptosis, mass– Vision loss– Proptosis (less prominent than primary)– > 90% unilateral
• Often aggressive and poorly differentiated• Systemic prognosis is poor
• Shields, et al. (2001)– 100 malignant neoplasms: 91 carcinomas
• Breast – 53• Prostate – 12• Lung – 8• Unknown primary – 7
– Thirteen presented first with orbital mets
• A number of published reports of metastasis to the extraocular muscles
• Including:– Loes, Wesley, & Lavin (1996)– Lekse, Zhang, & Mawn (2003)
• Report of such diffuse involvement?
Carcinoma of Unknown PrimaryCarcinoma of Unknown Primary• 2 - 4% of cancer diagnoses• Median survival: 4 - 5 mos• Treatment options have been poor
– Toxicity– Efficacy
• New chemotherapy regimens hold promise– Greco, et al. (2000) – combination of paclitaxel,
carboplatin, etoposide with median survival of 11 mos
ReferencesReferences• Greco, FA, et al. Carcinoma of Unknown Primary Site: Long term
follow-up after treatment with paclitaxel, carboplatin, and etoposide. Cancer 2000;89:2655-60.
• Henderson, JW Orbital Tumors. W.B. Saunders Company, Philadephia, 1973. pp 474-494.
• Kanski, JJ. Clinical Ophthalmology: A systematic Approach. 5th ed. Butterworth Heinemann, New York, 2003.
• Lekse, JM, et al. Metastatic gastroesophageal junction adenocarcinoma to the extraocular muscles. Opthalmology 2003;110:318-321
• Shields, JA, Shields, CL, et al. Cancer Metastatic to the Orbit: The 2000 Robert M. Curts Lecture. Ophthal Plast Reconstr Surg 2001;17:346-354.