Fluorescein angiographic findings in a case of cancer-associated retinopathy

Autoimmune retinopathy: clinical, electrophysiological, and immunological features in nine patients with long-term follow-up

PURPOSE

We aim to report on the clinical, imaging, immunological, and electrophysiological features of patients with autoimmune retinopathy (AIR) with long-term follow-up.

METHODS

Single-center, retrospective study of a consecutive group of AIR patients treated in a tertiary academic medical center.

RESULTS

Included were nine patients with a mean ± SD age at presentation of 65 ± 13 years and a median follow-up of 63 months (range 18-120). Five patients were known to have cancer. Median interval between onset of ocular symptoms and diagnosis of AIR was 36 months. Mean baseline and final LogMAR visual acuity were 0.72 ± 0.9 and 1.1 ± 1.2, respectively (p = 0.17). The most common funduscopic findings included optic atrophy and bone-spicule-like pigmentation. Thinning of the nerve fiber layer was the most frequent optical coherence tomographic abnormality. Electroretinographic (ERG) recordings demonstrated variably reduced cone- and rod-derived amplitudes in the majority of eyes at presentation. The most commonly detected anti-retinal antibody was anti-α-enolase. Treatment included immunomodulatory therapy and plasmapheresis. ERG tests showed stability in 64% of eyes throughout the treatment period.

CONCLUSION

This study highlights the importance of maintaining a high index of suspicion of AIR, particularly in late middle-aged and elderly patients with "unexplained" visual loss, in light of the non-specific posterior segment signs and the inconsistency of the routinely used ancillary tests.

A case of cancer-associated retinopathy with chorioretinitis and optic neuritis associated with occult small cell lung cancer

Background

Cancer-associated retinopathy (CAR) is associated with various malignancies, including small cell lung cancer (SCLC). It is difficult to recognize, but prompt diagnosis is crucial for the patient, as retinopathy may be a herald sign that precedes systemic manifestations by months, thus allowing early treatment of the underlying malignancy.

Case presentation

We present a rare case of CAR with chorioretinitis and optic neuritis in a patient with occult SCLC. The patient presented with rapidly progressive peripheral field loss and photopsias with “prism-like” visual disturbances. Her symptoms stabilized with intravenous methylprednisolone, and her cancer was treated with carboplatin, etoposide and radiotherapy.

Conclusions

This is the first reported case of SCLC-associated CAR to present with chorioretinitis. CAR can be a herald feature of SCLC, and early recognition of the disease should prompt a systemic evaluation for an occult malignancy, which may be critical for patient survival. Further understanding of CAR pathogenesis may offer potential avenues for treatment.

Autoimmune paraneoplastic syndromes associated to lung cancer: A systematic review of the literature: Part 3: Neurological paraneoplastic syndromes, involving the central nervous system

The development of new immune treatment in oncology and particularly for lung cancer may induce new complications, particularly activation or reactivation of auto-immune diseases. In this context, a systematic review on the auto-immune paraneoplastic syndromes that can complicate lung cancer appears useful. This article is the third of a series of five and deals mainly with neurological paraneoplastic syndromes involving the central nervous system.

The need for standardization of antiretinal antibody detection and measurement

PURPOSE

To review the current literature on the detection and measurement of antiretinal antibodies.

DESIGN

Collaborative essay.

METHODS

Literature review and interpretation.

RESULTS

There is strong evidence to suggest a role for antiretinal antibodies, particularly those targeting recoverin and alpha-enolase, in the pathogenesis of autoimmune retinopathy (AIR). Additionally, numerous other autoantibodies have been described as putative mediators of retinal degeneration and more remain to be discovered. However, assay methods described in the literature by many laboratories for the detection of circulating antiretinal antibodies have been varied and diverse, making it difficult to interpret and compare their results.

CONCLUSIONS

There is currently little standardization of laboratory methods used to detect and monitor antiretinal antibodies. To measure and monitor levels of circulating antiretinal antibodies optimally in patients with AIR, development of standardized assays with stringent internal controls is required. A multicenter collaborative and validation effort is encouraged to reach a consensus on this issue.

Cancer-associated retinopathy (CAR) with electronegative ERG: a case report

Cancer-associated retinopathy (CAR) should be suspected in patients who present with visual symptoms such as rapid unexplained visual loss and seeing shimmering lights, with an abnormal ERG. Electronegative ERG responses are not exclusive to melanoma-associated retinopathy (MAR) but may be seen in CAR as well. We describe a patient with CAR who presented with an electronegative ERG. A 67-year old woman, who presented with complaints of seeing shimmering lights, underwent an extensive ophthalmological and electrophysiological examination. Best-corrected visual acuity was 7/10 in the right and 9/10 in the left eye. Goldmann visual fields showed relative central scotomata and concentric narrowing. Slit-lamp and fundus examination were normal as was fluorescein angiography. Rod-specific ERG responses were severely reduced, with electronegative maximal combined rod-cone responses and delayed cone-responses with normal amplitudes. Melanoma-associated retinopathy was suspected. Extensive dermatological and internal evaluation eventually revealed an oat-cell carcinoma in the right lung. The patient died of pneumonia 2 years after presentation.

Recoverin as a cancer-retina antigen

In photoreceptor cells the Ca(2+) -binding protein recoverin controls phosphorylation of the visual receptor rhodopsin by inhibiting rhodopsin kinase (GRK-1). It can also serve as a paraneoplastic antigen in the development of retinal degeneration in some patients with cancer. The aberrant expression of recoverin in cancer cells and the presence of autoantibodies against recoverin are essential for the occurrence of cancer-associated retinopathy, which finally results in the apoptosis of photoreceptor cells. Noteworthy in cancer patients, the aberrant recoverin expression and the appearance of autoantibodies against recoverin are more frequent than paraneoplastic syndromes. We suggest the term "cancer-retina antigens" for this kind of proteins like recoverin that are solely expressed in retina and tumor tissues and evoke antibodies and/or T cells in patients with cancer. The rare development of a paraneoplastic syndrome is possibly caused by this immune response and probably depends on further events allowing to overcome the blood-retina barrier and the immune privileged status of the retina. It is still unknown whether aberrantly expressed recoverin could have a specific function in cancer cells, though it is suggested that it can be functionally associated with G-protein-coupled receptor kinases. This paper reviews the present knowledge on paraneoplastic syndromes associated with the aberrant expression of recoverin. A possible application of recoverin as a potential target for immunotherapy of cancer is discussed.

Management of paraneoplastic syndromes in lung cancer

Paraneoplastic syndromes are common complications of lung cancer. Although most frequently associated with advanced disease, paraneoplastic syndromes may also occur at early stages. Occasionally, the paraneoplastic syndrome may be the presenting symptom of lung cancer. For most paraneoplastic syndromes, the best treatment is to treat the underlying malignancy. However, in many cases, treatment of moderate efficacy or urgent therapy is required. Specific recommendations for the management of the most common paraneoplastic syndromes, including cachexia, hypercalcemia, and hyponatremia, are provided.

Paraneoplastic retinopathies and optic neuropathies

Unusual neuro-ophthalmologic symptoms and signs that go unexplained should warrant a thorough investigation for paraneoplastic syndromes. Although these syndromes are rare, these clinical manifestations can herald an unsuspected, underlying malignancy that could be treated early and aggressively. This point underscores the importance of distinguishing and understanding the various, sometimes subtle, presentations of ocular paraneoplastic syndromes. Outlined in this review article are diagnostic features useful in differentiating cancer-associated retinopathy, melanoma-associated retinopathy, and paraneoplastic optic neuropathy. These must also be distinguished from non-cancer-related eye disorders that may clinically resemble cancer-associated retinopathy. The associated antibodies and histopathology of each syndrome are presented to help in the understanding of these autoimmune phenomena. Treatment outcomes from reported cases are summarized, and some potential novel immunotherapies are also discussed.

Cancer-associated retinopathy associated with invasive thymoma

PURPOSE

To report a case of cancer-associated retinopathy associated with invasive thymoma.

DESIGN

Interventional case report.

METHOD

A 41-year-old Japanese woman was observed between February 1998 and May 2001. Ophthalmologic examinations and systemic examinations were performed. The patient received treatment including corticosteroid pulse therapy, plasmapheresis, and thymectomy.

RESULTS

The patient developed progressive visual dysfunction including bilateral visual acuity loss, concentric contraction of visual fields, and color vision loss. In both eyes, retinal vessel attenuation and retinal pigment epithelium degeneration were observed with fundus ophthalmoscopy and fluorescein angiography. Response in electroretinogram was reduced, suggesting both rod and cone dysfunction. Autoantibody against 23-kD cancer-associated retinopathy (CAR) antigen (antirecoverin antibody) was detected in the patient's serum. A mediastinal tumor that was histopathologically diagnosed as invasive thymoma was detected and was surgically resected. During more than 3 years of follow-up, no other malignancy was detected despite extensive systemic evaluation. The patient also suffered from subclinical myasthenia gravis. Although temporary improvement of visual function was observed after treatment with steroid pulse therapy and plasmapheresis' light perception of each eye was lost in the end.

CONCLUSIONS

The patient was diagnosed as having CAR. Invasive thymoma was considered to be the causative tumor because there had been no evidence that suggested other systemic malignancy during more than 3 years of follow-up.

Paraneoplastic syndromes associated with bronchogenic carcinoma

Paraneoplastic syndromes associated with lung cancer are diverse in their presentation, pathophysiology, and implications. They can be seen as a diagnostic and therapeutic challenge or as an opportunity to detect an otherwise asymptomatic malignancy. Unraveling the mechanisms that produce these syndromes will lead to insight into tumor biology that will be translated into novel approaches for early detection and therapy.