Ovarian adenocarcinoma with glaucoma: A case report
Introduction
Metastatic tumor accounts for the most common ocular malignancy in adults. In rare cases, ocular metastasis can represent the initial manifestation of an undiagnosed primary cancer such as breast and lung cancers. Patients usually present with visual field defects, ocular pain, floaters, photophobia, or blurred vision. Early symptoms of an ovarian adenocarcinoma are often vague, such as dyspepsia, abdominal distension, and bloating. It most commonly presents with abdominal or pelvic pain. Ovarian tumors remain confined to the peritoneal cavity in about 85% of the cases. But it can metastasize to pelvic and peri-aortic lymph nodes, as well as to the liver or lungs. Metastasis to the eye is very rare, and some cases may present with non-specific blurring of vision, photopsia, or visual disturbances, or even remain asymptomatic.
In this report, the authors describe the case of primary ovarian adenocarcinoma presenting with rubeosis iridis, glaucoma, and vitritis.
Case Report
A 53-year-old asthmatic female patient presented with a one-month history of pain and blurred vision in her right eye, while she had no complaints in the left eye. She was diagnosed with unilateral glaucoma in the right eye six months ago and was on topical therapy. On physical examination, her best-corrected visual acuity was 0.3, and 1.0 in the right and left eye, respectively. Intraocular pressure (IOP) of the right eye was high at 35 mm Hg whereas the left eye showed a normal value of 11 mm Hg. Slit-lamp biomicroscopy revealed ciliary injection, early cataracts, and flagrant rubeosis iridis in the right eye. Fundus was hazy with dense vitritis and there was a whitish choroidal shadow in the inferotemporal quadrant.
After hospitalization, physical examination revealed abdominal shifting dullness. Abdominal ultrasound was performed subsequently which revealed ascites and bilateral ovarian masses with peritoneal seeding. Bilateral ovarian masses (10 × 10 × 5 cm and 7 × 7 × 3 cm) with omental and peritoneal involvement were confirmed on laparoscopic bilateral salpingo-oophorectomy. Histopathological and cytological examinations. Laparoscopic bilateral salpingo-oophorectomy showed bilateral ovaria masses (10x10x5cm and 7x7x3cm) with metal and peritoneal involvement. Histopathological and cytological examinations confirmed a high-grade serous adenocarcinoma with multiple tumor implants.
Based on these observations, right pars plana vitrectomy was suggested to clear the vitreous haze, phacoemulsification to remove the cataract and the Posterior chamber intraocular lens (IOL) was implanted. Silicone oil was injected and left in the eye until the retina is stable.
The final diagnosis after the vitreous and choroidal biopsy was stage IV ovarian adenocarcinoma-associated metastasis to the choroid and florid rubeosis. Though the patient was transferred to oncology care for further management, she succumbed to her disease after the first cycle of chemotherapy.
DISCUSSION
Ovarian cancer is a highly metastatic and more than 70% of ovarian cancer patients are diagnosed with metastasis. The current case illustrates a rare site of metastasis for ovarian adenocarcinoma. It is now established that metastasis is the most common cause of intraocular malignancy.
Ovarian adenocarcinoma predominantly metastasizes within the peritoneal cavity and through the pelvic lymph nodes. Ovarian cancer metastasis to the central nervous system (CNS) is reported to occur in less than 1.5% of cases. A retrospective epidemiologic review of 4456 patients at The University of Texas M. D. Anderson Hospital and Tumor Institute revealed a 0.29% central nervous system metastases (n = 13). According to a clinicopathological study of 86 autopsied cases, the incidence of CNS metastases was 1.2%. Halassy et al reviewed 57 articles detailing the accounts of 591 patients with brain metastasis from ovarian cancers. The median age was 54.3 years (range 20-81) with the majority of patients (57.3%) suffering from multiple brain lesions after being diagnosed with primary cancer. Though 9% reported visual disturbances, none had ocular metastasis. Zhang et al reported 9 cases of ovarian tumors metastasizing into the central nervous system with headache as the main presenting symptom and the frontal lobe the most likely affected site.
Recent evidence suggests the possibility of ocular metastasis in patients with ovarian adenocarcinoma. In some previous studies, the left eye was more frequently affected, and it has been proposed to be related to the direct path provided by the left common carotid originating from the aorta. The choroid is the most common ocular site of metastases, accounting for more than 80% of cases. Ocular metastases are generally asymptomatic. Some cases may present with non-specific symptoms including blurring of vision, visual impairment, or photopsia. Roels et al reported unilateral paraneoplastic retinopathy in a patient with ovarian carcinoma, but with no metastasis.
Conclusion
There is no documented case in the literature of intraocular metastasis in a patient with primary ovarian adenocarcinoma. This case represents the first documented report of ocular metastasis from a bilateral ovarian adenocarcinoma.
Awareness of the intraocular metastases from the gynecological primary, a detailed ophthalmic examination, and a high index of suspicion will aid in arriving at the right diagnosis of underlying diseases including malignancies.
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