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Research Letters |

Acute Exudative Polymorphous Paraneoplastic Vitelliform Maculopathy in a Patient With Carcinoma, Not Melanoma FREE

Lili Grunwald, MD; Brad E. Kligman, BS; Carol L. Shields, MD
[+] Author Affiliations

Author Affiliations: Department of Ophthalmology, Duke University Eye Center, Durham, North Carolina (Dr Grunwald); and Ocular Oncology Service, Wills Eye Institute, Thomas Jefferson University, Philadelphia, Pennsylvania (Mr Kligman and Dr Shields).


Arch Ophthalmol. 2011;129(8):1104-1106. doi:10.1001/archophthalmol.2011.215.
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Published online

Paraneoplastic retinopathy occurs when autoantibodies against cancer cross-react with normal retinal antigens and lead to retinal degeneration and subsequent vision loss.1 Two main categories of paraneoplastic retinopathies have been described, including cancer-associated retinopathy and melanoma-associated retinopathy.2 Cancer-associated retinopathy is found most often in patients with small cell lung carcinoma and affects both rod and cone function, while melanoma-associated retinopathy occurs with metastatic cutaneous or uveal melanoma and affects primarily rod function.1 Autoantibodies against recoverin and bipolar cells are typically found in cancer-associated retinopathy and melanoma-associated retinopathy, respectively, although other retinal antigens have also been described.1,3 Herein, we illustrate a case of a more recently recognized paraneoplastic retinopathy, termed acute exudative polymorphous paraneoplastic vitelliform maculopathy (AEPPVM).

A 69-year-old woman noted gradually progressive blurred vision in both eyes over 2 years. Three months previously, she experienced subjective loss of peripheral vision bilaterally. Other symptoms included mild decreased night vision and photopsia. Stage I breast cancer was diagnosed 5 years prior and treated with excisional biopsy and radiotherapy. She had a second cancer, stage IV lung cancer with liver metastasis, that was diagnosed 2 years prior and was treated with chemotherapy.

On examination, best-corrected visual acuity was 20/80 OD and 20/70 OS. The anterior segment, optic disc, and retinal vessels were unremarkable bilaterally. Fundus examination revealed multiple small, round, amelanotic (vitelliform) lesions approximately 500 μm in diameter in the postequatorial region bilaterally that superficially appeared like choroidal metastasis or retinal pigment epithelial detachments (Figure 1). There was no vitritis. Ultrasonography showed multifocal regions of chorioretinal thickening. Optical coherence tomography revealed multiple areas of localized subretinal fluid with debris overlying flat retinal pigment epithelium (Figure 2). Autofluorescence disclosed hyperautofluorescence corresponding to the serous retinal detachments (Figure 1), whereas fluorescein angiography demonstrated hypofluorescence of these regions with no leakage (Figure 2). The patient refused electroretinography testing.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Fundus photographs of the right (A) and left (B) eyes show numerous subtle hypopigmented subretinal lesions (arrows) corresponding to multifocal serous detachments of the neurosensory retina. Autofluorescence of the right (C) and left (D) eyes reveals hyperautofluorescence (arrows) in the area of the serous retinal detachment.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Optical coherence tomographic image and fluorescein angiograms. A, Optical coherence tomography shows multiple serous neurosensory retinal detachments with optically dense debris. Fluorescein angiograms show hypofluorescence of the lesion in early frames in the right (B) and left (C) eyes and late frames in the right (D) and left (E) eyes.

This case illustrates an unusual cause of vision loss in a patient with systemic cancer, namely AEPPVM. This condition manifests with multiple vitelliform lesions and is considered an atypical subset of cancer-associated retinopathy or melanoma-associated retinopathy or a separate paraneoplastic entity. Several authors have associated this entity with underlying cutaneous and choroidal melanoma, but not carcinoma.36 Previous reports have labeled this condition as Vogt-Koyanagi-Harada–like syndrome, melanoma-associated retinopathy syndrome variant, vitelliform maculopathy with skin melanoma, vitelliform paraneoplastic retinopathy associated with melanoma, and AEPPVM.36 While most previously reported cases have occurred in patients with skin or eye melanoma, we are unaware of reports of this condition with carcinoma, as in our case.

Clinicians should be aware of AEPPVM. Differentiation from choroidal metastasis can be made by clinical examination and more specifically by optical coherence tomography in that the choroid is flat in AEPPVM, whereas it is elevated with choroidal metastases. In our case, optical coherence tomography showed elevated retina and flat choroid, consistent with AEPPVM. Superficially, the optical coherence tomography changes resembled pigment epithelial detachment, but close scrutiny disclosed flat retinal pigment epithelium and subretinal fluid with dense debris.

Symptoms from paraneoplastic retinopathy can occur before or after the discovery of the primary malignant neoplasm.1,2 Systemic evaluation for primary cancer, particularly cutaneous or uveal melanoma, is indicated. In our case, systemic evaluation showed no sign of melanoma, and the previously diagnosed carcinomas were confirmed. There is a remote possibility that our patient could have had a regressed cutaneous melanoma or undetected visceral melanoma.

In summary, we describe an unusual paraneoplastic syndrome, namely AEPPVM. This condition should be recognized by clinicians, and systemic evaluation for the primary malignant neoplasm should be performed owing to the high association with cutaneous and choroidal melanoma and, now, carcinoma.1

Correspondence: Dr C. L. Shields, Ocular Oncology Service, Ste 1440, Wills Eye Institute, 840 Walnut St, Philadelphia, PA 19107 (carol.shields@shieldsoncology.com).

Financial Disclosure: None reported.

Funding/Support: This work was supported by the Eye Tumor Research Foundation, Philadelphia, Pennsylvania (Dr Shields).

Chan JW. Paraneoplastic retinopathies and optic neuropathies.  Surv Ophthalmol. 2003;48(1):12-38
PubMed   |  Link to Article
Thirkill CE. Cancer-induced, immune-mediated ocular degenerations.  Ocul Immunol Inflamm. 2005;13(2-3):119-131
PubMed   |  Link to Article
Bianciotto C, Shields CL, Thirkill CE, Materin MA, Shields JA. Paraneoplastic retinopathy with multiple detachments of the neurosensory retina and autoantibodies against interphotoreceptor retinoid binding protein (IRBP) in cutaneous melanoma.  Br J Ophthalmol. 2010;94(12):1684-1685, 1696
PubMed   |  Link to Article
Borkowski LM, Grover S, Fishman GA, Jampol LM. Retinal findings in melanoma-associated retinopathy.  Am J Ophthalmol. 2001;132(2):273-275
PubMed   |  Link to Article
Palmowski AM, Haus AH, Pföhler C,  et al.  Bilateral multifocal chorioretinopathy in a woman with cutaneous malignant melanoma.  Arch Ophthalmol. 2002;120(12):1756-1761
PubMed
Sotodeh M, Paridaens D, Keunen J, van Schooneveld M, Adamus G, Baarsma S. Paraneoplastic vitelliform retinopathy associated with cutaneous or uveal melanoma and metastases.  Klin Monbl Augenheilkd. 2005;222(11):910-914
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Fundus photographs of the right (A) and left (B) eyes show numerous subtle hypopigmented subretinal lesions (arrows) corresponding to multifocal serous detachments of the neurosensory retina. Autofluorescence of the right (C) and left (D) eyes reveals hyperautofluorescence (arrows) in the area of the serous retinal detachment.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Optical coherence tomographic image and fluorescein angiograms. A, Optical coherence tomography shows multiple serous neurosensory retinal detachments with optically dense debris. Fluorescein angiograms show hypofluorescence of the lesion in early frames in the right (B) and left (C) eyes and late frames in the right (D) and left (E) eyes.

Tables

References

Chan JW. Paraneoplastic retinopathies and optic neuropathies.  Surv Ophthalmol. 2003;48(1):12-38
PubMed   |  Link to Article
Thirkill CE. Cancer-induced, immune-mediated ocular degenerations.  Ocul Immunol Inflamm. 2005;13(2-3):119-131
PubMed   |  Link to Article
Bianciotto C, Shields CL, Thirkill CE, Materin MA, Shields JA. Paraneoplastic retinopathy with multiple detachments of the neurosensory retina and autoantibodies against interphotoreceptor retinoid binding protein (IRBP) in cutaneous melanoma.  Br J Ophthalmol. 2010;94(12):1684-1685, 1696
PubMed   |  Link to Article
Borkowski LM, Grover S, Fishman GA, Jampol LM. Retinal findings in melanoma-associated retinopathy.  Am J Ophthalmol. 2001;132(2):273-275
PubMed   |  Link to Article
Palmowski AM, Haus AH, Pföhler C,  et al.  Bilateral multifocal chorioretinopathy in a woman with cutaneous malignant melanoma.  Arch Ophthalmol. 2002;120(12):1756-1761
PubMed
Sotodeh M, Paridaens D, Keunen J, van Schooneveld M, Adamus G, Baarsma S. Paraneoplastic vitelliform retinopathy associated with cutaneous or uveal melanoma and metastases.  Klin Monbl Augenheilkd. 2005;222(11):910-914
PubMed   |  Link to Article

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