[Skip to Content]
[Skip to Content Landing]

Rapidly Progressive Vision Loss in a Patient With Breast Cancer

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 67-year-old white female patient with metastatic breast cancer, currently taking capecitabine plus trastuzumab, presented with 2 weeks of painless reduced vision in her right eye (OD). Her breast cancer was diagnosed in 2007 as stage IA estrogen-receptor positive, progesterone-receptor negative (ER+, PR−), and human epidermal growth factor 2 (ERBB2; formerly HER2) negative, initially treated with lumpectomy plus left breast radiotherapy followed by doxorubicin, cyclophosphamide, paclitaxel, and anastrazole. In 2017, metastases were found in the lumbar spine and lung and treated with fulvestrant and palbociclib plus left brachial plexus radiotherapy. Later, progressive liver metastasis and repeat biopsy with equivocal ERBB2 testing led to treatment with capecitabine plus trastuzumab.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Breast cancer with bilateral choroidal metastases

C. Obtain MRI of the head and orbits

The key to the correct diagnosis of bilateral choroidal metastases is the recognition of characteristic solid yellow choroidal tumors with subretinal fluid in a patient with known metastatic cancer. MRI confirmed a lesion in the posterior right globe in addition to multiple metastases in the cerebellum (Figure 2). Ocular adverse effects from chemotherapy do not manifest as solid choroidal tumors, and treatment should be continued. Both corticosteroids and intravitreal anti-VEGF are not proven in treating choroidal metastases.1,2

The differential diagnosis for vision changes in a patient undergoing treatment for malignancy is broad and includes tumor invasion into ocular or neural structures, paraneoplastic syndromes, secondary vascular disease, and adverse effects of chemotherapy or radiotherapy. Thus, prompt ophthalmic evaluation is important for patients with cancer who have persistent visual symptoms.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: Carol L. Shields, MD, Ocular Oncology Service, Wills Eye Hospital, 840 Walnut St, Ste 1440, Philadelphia, PA 19107 (carolshields@gmail.com).

Published Online: August 22, 2019. doi:10.1001/jama.2019.12691

Conflict of Interest Disclosures: None reported.

Funding/Support: Support provided, in part, by the Eye Tumor Research Foundation (Dr Shields).

Role of the Funder/Sponsor: The Eye Tumor Research Foundation had no role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Augustine  H, Munro  M, Adatia  F, Webster  M, Fielden  M.  Treatment of ocular metastasis with anti-VEGF.  Can J Ophthalmol. 2014;49(5):458-463.PubMedGoogle ScholarCrossref
2.
Maudgil  A, Sears  KS, Rundle  PA, Rennie  IG, Salvi  SM.  Failure of intravitreal bevacizumab in the treatment of choroidal metastasis.  Eye (Lond). 2015;29(5):707-711.PubMedGoogle ScholarCrossref
3.
Nelson  CC, Hertzberg  BS, Klintworth  GK.  A histopathologic study of 716 unselected eyes in patients with cancer at the time of death.  Am J Ophthalmol. 1983;95(6):788-793.PubMedGoogle ScholarCrossref
4.
Shields  CL, Welch  RJ, Malik  K,  et al.  Uveal metastasis: clinical features and survival outcome of 2214 tumors in 1111 patients based on primary tumor origin.  Middle East Afr J Ophthalmol. 2018;25(2):81-90.PubMedGoogle ScholarCrossref
5.
Shields  CL, Kaliki  S, Furuta  M, Mashayekhi  A, Shields  JA.  Clinical spectrum and prognosis of uveal melanoma based on age at presentation in 8,033 cases.  Retina. 2012;32(7):1363-1372.PubMedGoogle ScholarCrossref
6.
Horgan  N, Shields  CL, Mashayekhi  A, Shields  JA.  Classification and treatment of radiation maculopathy.  Curr Opin Ophthalmol. 2010;21(3):233-238.PubMedGoogle ScholarCrossref
7.
Waikhom  B, Fraunfelder  FT, Henner  WD.  Severe ocular irritation and corneal deposits associated with capecitabine use.  N Engl J Med. 2000;343(10):740-741.PubMedGoogle ScholarCrossref
8.
Tang  R, Shields  J, Schiffman  J,  et al.  Retinal changes associated with tamoxifen treatment for breast cancer.  Eye (Lond). 1997;11(Pt 3):295-297.PubMedGoogle ScholarCrossref
9.
Esmaeli  B, Hidaji  L, Adinin  RB,  et al.  Blockage of the lacrimal drainage apparatus as a side effect of docetaxel therapy.  Cancer. 2003;98(3):504-507.PubMedGoogle ScholarCrossref
10.
Rudoler  SB, Shields  CL, Corn  BW,  et al.  Functional vision is improved in the majority of patients treated with external-beam radiotherapy for choroid metastases.  J Clin Oncol. 1997;15(3):1244-1251.PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Topics
State Requirements