Bilateral Choroidal Metastases from Breast Carcinoma: A Case Report with Multimodal Imaging

Introduction: Choroidal metastases are the most common intraocular malignancies, with breast carcinoma being the leading primary tumor in women. Bilateral involvement associated with exudative retinal detachment is uncommon and potentially sight-threatening. Case Presentation: A 31-year-old black woman with a history of left breast carcinoma treated by mastectomy and adjuvant chemoradiotherapy presented with progressive visual loss and photopsia in both eyes. Fundus examination revealed bilateral exudative retinal detachment with macular involvement in the left eye. Multimodal imaging using fundus photography, B-scan ultrasonography and computed tomography demonstrated bilateral choroidal masses consistent with metastatic disease. Despite referral for systemic oncological management, the patient declined chemotherapy and was followed for 33 days, showing progression of the choroidal lesions. Conclusion: Choroidal metastases should be suspected in any patient with breast cancer presenting with visual symptoms. Multimodal ocular imaging is crucial for diagnosis.

• Breast Cancer
• Ocular Metastasis
• Multimodal Imaging
• Young Woman

1. Introduction

According to the World Health Organization (WHO), breast cancer is the most common cancer in women, with an estimated 2.3 million new cases in 2022 [1]. Metastases from this cancer are most commonly found in the bones, liver, lungs, skin, and brain [2]. Ocular localization, more specifically choroidal localization, remains rare and there is little literature on the subject. It is a source of visual impairment in patients with breast cancer. We report a case of bilateral retinal detachment secondary to choroidal metastases from primary breast cancer.

2. Case Presentation

This was a 31-year-old female patient who was admitted to the ophthalmology department of Bogodogo University Hospital for decreased visual acuity in her left eye associated with phosphenes in both eyes. The onset of symptoms dated back approximately three months, marked by the appearance of phosphenes first in the left eye, then in the right eye. Then, approximately two weeks before the consultation, a rapidly progressive BAV occurred in the left eye, which prompted the consultation. The patient had a history of invasive carcinoma of the left breast for 13 months, for which she had undergone a left mastectomy and adjuvant radiotherapy and chemotherapy. The patient had interrupted the adjuvant chemotherapy sessions against medical advice in order to seek treatment from a traditional healer.

The patient’s general condition was impaired, at grade 3 on the WHO performance scale. Consciousness was normal with a Glasgow score of 15/15.

The ophthalmological examination revealed distance visual acuity of 0 logMAR in the right eye and limited to +2 logMAR in the left eye. Examination of the adnexa and anterior segment was normal in both eyes. Intraocular pressure was 11 mmHg in the right eye and 10 mmHg in the left eye. Fundus examination revealed bilateral retinal detachment with macula off in the left eye (Figures 1-2). There was no vitreoretinal dehiscence or proliferation in either eye.

Figure 1

Figure 1.Retinophotography of the right eye on the day of consultation showing a macula-off retinal detachment.

Figure 2

Figure 2.Retinophotography of the left eye on the day of the consultation showing retinal detachment in the inferior nasal region.

B-mode ocular ultrasound revealed bilateral retinal detachment with heterogeneous posterior hyperechogenicity (Figure 3). Computed tomography revealed spontaneously hyperdense and heterogeneous tissue thickening of the posterior wall of the globe, more extensive on the left, consistent with tumor masses (Figure 4).

3. Management and Follow-Up

An oncological evaluation was requested with a view to systemic chemotherapy. However, the patient did not have the financial means to undergo tumor staging and refused any further chemotherapy. She was reviewed on day 16 and day 33 after the initial consultation. Retinography showed progression of the choroidal lesions, particularly in the left eye (Figures 5-8). The patient was lost to follow-up after the appointment on day 33.

Figure 3

Figure 3.B-mode ocular ultrasound showing bilateral retinal detachment.

Figure 4

Figure 4.Craniofacial CT scan showing bilateral tissue thickening of the posterior wall of the globe.

Figure 5

Figure 5. Retinophotography of the right eye on day 16 after consultation showing a multilobular retinal mass.

Figure 6

Figure 6. Retinophotography of the right eye on day 33 post-consultation showing a retinal mass obscuring almost the entire posterior pole.

Figure 7

Figure 7. Retinophotography of the left eye on day 16 after consultation showing a retinal mass in the lower nasal area.

Figure 8

Figure 8. Retinophotography of the left eye on day 33 post-consultation showing slight progression toward the posterior pole of the retinal mass in the inferonasal quadrant.

4. Discussion

Choroidal metastases account for 90% of all uveal metastases according to Shields et al. [3]. The most common primary tumor site is the breast in women and the lung in men [3]. The time between diagnosis of breast cancer and ocular metastases varies according to studies, depending on the nature of the primary cancer but also on the treatment. Ocular metastases were discovered in our patient 13 months after excision of the primary cancer. Randhawa et al. reported choroidal metastases occurring 34 years after excision of the primary tumor, highlighting the need for lifelong monitoring [4]. Other studies have reported cases where ocular metastases revealed primary breast cancer [5][6]. B-mode ocular ultrasound and computed tomography were of great diagnostic value to us. Sanayei et al. also reported the importance of B-mode ultrasound in the diagnosis of these ocular tumors [7]. Optical coherence tomography and magnetic resonance imaging are said to be more accurate [8]. The occurrence of these metastases highlights the discipline and perfect cooperation required of such a patient for optimal care. The patient’s transition to a traditional healer highlights the need for better patient education and psychological support during difficult treatments such as chemotherapy. The macular involvement on the left side explains the profound decline in visual function. A combined therapeutic approach combining systemic treatment with local treatment could be beneficial in this patient, who is affected by the lack of technical facilities in our context [9]. Although the systemic prognosis is often poor, local treatments such as external radiotherapy can sometimes help preserve vision and improve quality of life during the remaining months [3]. A multidisciplinary approach remains essential for optimal care.

5. Conclusion

This is a rare case of bilateral retinal detachment of metastatic origin. The diagnosis was relatively straightforward, guided by clinical examination and aided by B-mode ocular ultrasound and computed tomography. The onset of visual disturbances in a woman with breast cancer should raise suspicion of this diagnosis and prompt a thorough ophthalmological examination.

References

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