Ocular diseases in metastatic cutaneous melanoma: review of 108 consecutive patients in two German tertiary centers

Idiopathic acute exudative polymorphous vitelliform maculopathy: the importance of multimodal imaging, systemic workup and genetic testing

The authors describe a case of acute exudative polymorphous vitelliform maculopathy (AEPVM) in an otherwise healthy man in his 60s complaining of subacute bilateral blurred vision. At examination, best-corrected visual acuity was 20/32 in the right eye and 20/40 in the left eye. Bilateral central large serous detachments with inferior meniscus-like deposition of a vitelliform-like material were observed at funduscopy and confirmed by spectral-domain optical coherence tomography. Small vitelliform-like lesions along the temporal superior vascular arcades were also seen. The lesions with vitelliform appearance appeared hyperautofluorescent on fundus autofluorescence. A complete systemic workup and genetic testing were performed and the diagnosis of idiopathic AEPVM was established. Six months later, a complete resolution of the lesions was observed.

Recurrence of Pancreatic Cancer Presenting as Choroidal Metastasis: A Case Report

A patient initially diagnosed as having central serous chorioretinopathy (CSC) presented to a clinic with recurrence of pancreatic cancer manifesting as choroidal metastasis. He was initially diagnosed with CSC by a local ophthalmologist 8 weeks earlier and subsequently presented to our clinic for second opinion after further loss of vision. His medical history was significant for locally advanced pancreatic cancer that was resected by pancreaticoduodenectomy and was treated with adjuvant Folfirinox chemotherapy that was completed 12 months earlier. On examination, there was a large serous retinal detachment overlying a large pale ill-defined elevated choroidal lesion. A diagnosis of choroidal metastasis from recurrence of his pancreatic cancer was made. The diagnosis of choroidal metastasis of his pancreatic cancer represented recurrence of his pancreatic cancer that is associated with high mortality. Early recognition by clinical assessment may allow timely management with chemotherapy and radiation, and potentially prolong survival.

Fundus Autofluorescence and Clinical Applications

Fundus autofluorescence (FAF) has allowed in vivo mapping of retinal metabolic derangements and structural changes not possible with conventional color imaging. Incident light is absorbed by molecules in the fundus, which are excited and in turn emit photons of specific wavelengths that are captured and processed by a sensor to create a metabolic map of the fundus. Studies on the growing number of FAF platforms has shown each may be suited to certain clinical scenarios. Scanning laser ophthalmoscopes, fundus cameras, and modifications of these each have benefits and drawbacks that must be considered before and after imaging to properly interpret the images. Emerging clinical evidence has demonstrated the usefulness of FAF in diagnosis and management of an increasing number of chorioretinal conditions, such as age-related macular degeneration, central serous chorioretinopathy, retinal drug toxicities, and inherited retinal degenerations such as retinitis pigmentosa and Stargardt disease. This article reviews commercial imaging platforms, imaging techniques, and clinical applications of FAF.

Acute exudative polymorphous paraneoplastic vitelliform maculopathy (AEPPVM) associated with choroidal melanoma

Background

To report a case of acute exudative polymorphous paraneoplastic vitelliform maculopathy in a patient with a history of choroidal melanoma, with metastases to the pancreas, liver, and central nervous system.

Case presentation

A 63-year-old patient, with a history of enucleation of the right eye due to choroidal melanoma, complained of progressive visual loss during a follow-up visit. Fundoscopic examination revealed multiple small areas of serous retinal detachment scattered throughout the posterior pole and ancillary tests confirmed the diagnosis of acute exudative polymorphous paraneoplastic vitelliform maculopathy (AEPPVM). Screening for systemic metastases showed pancreatic, hepatic, and central nervous system involvement.

Conclusions

We describe a rare case of acute exudative polymorphous paraneoplastic vitelliform maculopathy, which should be considered in patients with or without a history of melanoma, who have vitelliform retinal detachments. Nevertheless, no previous reviews of literature have shown a correlation between AEPPVM and pancreatic metastasis.

[MEK inhibitor-associated retinopathy under binimetinib treatment for cutaneous malignant melanoma]

Die Behandlungsmöglichkeiten für Patienten mit metastasierendem Melanom (MM) wurden in den letzten Jahren mit der Zulassung von neuen Medikamenten dramatisch erweitert. Die MEK(mitogen-aktivierte Proteinkinase-Kinasen)- und BRAF(Serin/Threonin-Kinase B-Raf kodierendes Gen)-Hemmer-Kombinationstherapie gehört aktuell zum Versorgungsstandard für das Stadium IIIC/IV des BRAF-mutierten Melanoms. MEKAR (MEK-Inhibitor-assoziierte Retinopathie) werden bei Patienten mit metastasierendem Melanom beobachtet, die mit einer solchen Kombinationstherapie behandelt werden bzw. wurden. Wir berichten über den Fall eines 72-jährigen Patienten, der eine solche Pathologie unter der Therapie mit Binimetinib in Kombination mit Nivolumab erlitt. Diese Kasuistik verdeutlicht die Wichtigkeit einer interdisziplinären Zusammenarbeit bei der Behandlung von MM-Patienten.

Paraneoplastic acute exudative polymorphous vitelliform maculopathy improved with intravitreal methotrexate

Purpose

To describe a case of acute exudative polymorphous vitelliform maculopathy (AEPVM) treated with intravitreal methotrexate.

Observations

A 58-year-old man with a history of metastatic melanoma developed paraneoplastic acute exudative polymorphous vitelliform maculopathy, refractory to oral prednisone, intravitreal bevacizumab and intravitreal preservative-free triamcinolone. Improvement in vision and resolution of subfoveal fluid was later seen after intravitreal methotrexate therapy.

Conclusions and Importance

AEPVM is a rare and poorly understood retinal disorder that may be idiopathic or may manifest in patients with malignancies. The pathogenic process is thought to be an attack directed against the retinal pigment epithelium (RPE) and photoreceptors. Intravitreal methotrexate may provide benefit when treating AEPVM, especially when trials of steroids and anti-VEGF medications have failed.

Acute Exudative Polymorphous Vitelliform Maculopathy Syndrome; natural history and evolution of fundal and OCT images over time

A 33-year-old man presented with a 10-day history of bilateral blurred vision on a background of a prodromal influenza-like illness. Ocular Coherence Tomography (OCT) and fundal examination coincided with a diagnosis of atypical central serous retinopathy. The patient's symptoms worsened during follow-up, and he was started on steroids. Subsequent fundal examination revealed yellow deposits in a honeycomb pattern and hard exudates in the perimacular region. Serial OCTs revealed progression of bilateral macular intraretinal and subretinal fluid. He was subsequently admitted to hospital for a full paraneoplastic workup. Liaison with our colleagues in other specialist retinal centres led us to a diagnosis of acute exudative polymorphous vitelliform maculopathy syndrome. We subsequently took fundal images to monitor disease progression and to monitor changes seen with autofluorescence in this rare disease entity.

Successful long-term treatment of paraneoplastic optic neuropathy with mycophenolate mofetil, prednisone, and plasmapheresis

Purpose

To report long-term follow-up of a case of paraneoplastic optic neuropathy (PON) successfully treated with combination therapy.

Observations

We present a confirmed case of PON from cutaneous melanoma with nearly six years of meticulous follow-up in which vision was preserved and disease remission was successfully induced with combination mycophenolate mofetil, prednisone, and plasmapheresis therapy.

Conclusions and importance

Treatment of PON and long-term follow-up are not well described in the literature. In our case of PON, vision was preserved and disease remission was achieved with mycophenolate mofetil, prednisone, and plasmapheresis. Such information may be useful for future cases of PON.

PARANEOPLASTIC VITELLIFORM MACULOPATHY ASSOCIATED WITH METASTATIC MELANOMA

PURPOSE

To report a case of paraneoplastic vitelliform maculopathy in a patient with metastatic melanoma of unknown primary site.

METHODS

Case report. Main outcome measures include funduscopic examination, fluorescein angiography, fundus autofluorescence, and spectral domain optical coherence tomography.

RESULTS

A 44-year-old man with a known history of metastatic melanoma was referred for ophthalmic evaluation because of bilateral vision loss. Funduscopic examination was remarkable for vitelliform maculopathy that was confirmed with fundus autofluorescence and spectral domain optical coherence tomography.

CONCLUSION

We describe a rare case of paraneoplastic vitelliform maculopathy. There are many etiologies of acquired vitelliform retinal lesions in the retina. Multimodal retinal imaging, including fundus autofluorescence and spectral domain optical coherence tomography, can be best used to identify these lesions. A history of systemic metastatic melanoma should be ruled out in patients with vitelliform maculopathy.

PARANEOPLASTIC VITELLIFORM MACULOPATHY IN THE SETTING OF CHOROIDAL MELANOMA: EVOLUTION OVER ONE YEAR

BACKGROUND

To illustrate the evolution of paraneoplastic vitelliform maculopathy over one year using optical coherence tomography.

METHODS

Observational case report.

RESULTS

A 65-year-old man with a history of ocular melanocytosis and choroidal melanoma of the left eye treated with plaque brachytherapy 3 years prior returned for his yearly follow-up visit. The visual acuity in the right eye was 20/20. Subtle thickening of the interdigitation zone layer was noted on optical coherence tomography. Over the following year, multifocal vitelliform detachments developed with progressive enlargement and coalescence of the lesions. Paraneoplastic vitelliform maculopathy developed in the fellow eye of a patient with local recurrence of previously treated choroidal melanoma.

CONCLUSION

Paraneoplastic vitelliform maculopathy may develop in the fellow eye of a patient with local recurrence of their previously treated choroidal melanoma with no clinical evidence of systemic metastasis.

Clinical applications of fundus autofluorescence in retinal disease

Fundus autofluorescence (FAF) is a non-invasive retinal imaging modality used in clinical practice to provide a density map of lipofuscin, the predominant ocular fluorophore, in the retinal pigment epithelium. Multiple commercially available imaging systems, including the fundus camera, the confocal scanning laser ophthalmoscope, and the ultra-widefield imaging device, are available to the clinician. Each offers unique advantages for evaluating various retinal diseases. The clinical applications of FAF continue to expand. It is now an essential tool for evaluating age related macular degeneration, macular dystrophies, retinitis pigmentosa, white dot syndromes, retinal drug toxicities, and various other retinal disorders. FAF may detect abnormalities beyond those detected on funduscopic exam, fluorescein angiography, or optical coherence tomography, and can be used to elucidate disease pathogenesis, form genotype-phenotype correlations, diagnose and monitor disease, and evaluate novel therapies. Given its ease of use, non-invasive nature, and value in characterizing retinal disease, FAF enjoys increasing clinical relevance. This review summarizes common ocular fluorophores, imaging modalities, and FAF findings for a wide spectrum of retinal disorders.

Exudative Polymorphous Vitelliform Retinopathy: Importance of Early Recognition of the Condition in Patients with Metastatic Melanoma

Introduction

Because of the advent of monoclonal antibodies in the treatment of metastatic melanoma, patients with this disease are surviving longer. Early recognition of the disease has therefore become even more important.

Case report

We present a patient with vitelliform maculopathy, a paraneoplastic retinal maculopathy that is under-recognized. Clinically the retinal findings of serous detachments and pigmentary macular changes are remarkable, while at the same time these patients have surprisingly very few symptoms. This is in contrast to patients who develop melanoma associated retinopathy (MAR) who are very symptomatic early in the disease, but with more subtle retinal findings.

Conclusion

Monoclonal antibody treatment is changing the survival rates in metastatic disease making early diagnosis even more important. Exudative polymorphous vitelliform maculopathy (EPVM) needs to be recognized early to avoid delay in diagnosis of metastatic disease.

Choroidal metastases from thymic carcinoma during pregnancy: Case Report

BACKGROUND

Rare sites of metastases, atypical symptoms and paraneoplastic syndromes are often neglected or misinterpreted, especially when they represent early symptoms of an underlying malignant disease. Hence, an interdisciplinary approach to these patients is essential to avoid tumor progression and metastatic spread in order to provide curative treatment options to the patients. We here report the case of a young woman presenting with visual loss which led to diagnosis of a thymic carcinoma.

CASE PRESENTATION

A 28-year old white woman presented with subacute loss of vision in the last trimester of her first pregnancy which was first interpreted as an exacerbation of a pre-existing dermatomyositis and treated with steroids. After failure of steroid therapy choroidal metastases from an undifferentiated thymic carcinoma were diagnosed. This also shed a new light on the dermatomyositis the patient had been suffering from for seven years possibly representing a paraneoplastic syndrome from the tumor. Despite aggressive chemotherapy, the patient died from progressive disease eight years after first onset of dermatomyositis and 14 months after initial diagnosis of the thymic carcinoma.

CONCLUSIONS

Choroidal metastases from a thymic carcinoma have never been reported before but should be included into the differential diagnosis of choroidal masses.

A case of acute exudative polymorphous vitelliform maculopathy: follow-up and wide-field spectral-domain optical coherence tomography

PURPOSE

To present a case of an HIV-positive patient with acute exudative polymorphous vitelliform maculopathy (AEPVM) and evaluate the presence of specific spectral-domain optical coherence tomography (SD-OCT) findings.

METHODS

Case report.

RESULTS

We reviewed the AEPVM cases reported in the literature and compared those to our patient to determine if there is a correspondence between the etiology that leads to the onset of AEPVM and clinical and SD-OCT findings.

CONCLUSIONS

Acute exudative polymorphous vitelliform maculopathy is a disease that involves the outer retinal layers with lipofuscin deposits and serous detachment of the neuroepithelium with or without intraretinal cysts. Not much is known about the etiology and pathogenesis, and not many cases have been described. A review of the few clinical cases reported in the literature does not show a specific correspondence between etiology and SD-OCT findings.