Download Taylor, M

First author: Megan Taylor, OD, Columbus VAACC/Chillicothe VAMC
Co-author: Pete Liette, OD, Auxiliary Faculty at The Ohio State University College of
Optometry/Staff Optometrist at Columbus VAACC
Vague Visual Complaints and Field Deficits as Only Presenting Sign for Metastatic Brain Disease
– A Case Report
This unique case demonstrates how visual field defects were the first and only presenting
symptom for multiple metastatic brain tumors and that prompt and proper referrals helped
prolong the patient’s life.
I. Case history
a. Patient demographics: 73 year old white male
b. Chief complaint: blurred vision OS for several months
c. Ocular history
i. lamellar macular hole OD, epiretinal membrane OU, mild age related
cataracts OU, dry eye syndrome OU, hyperopic astigmatism OU
d. Medical history
i. ENT: hearing impairment
ii. Cardiovascular: hypertension
iii. Gastrointestinal: colon polyps, diverticulitis, GERD
iv. Genitourinary: impotence, elevated PSA, BPH, hematuria, chronic kidney
disease stage 1
v. Musculoskeletal: osteopenia, lumbago
vi. Neurological: longstanding benign tremor
vii. Psychiatric: insomnia, panic disorder, agoraphobia
viii. Endocrine: hyperparathyroidism, multinodular goiter
ix. Hematologic: vitamin D deficiency
x. Immunologic: rheumatoid arthritis
e. Medications
i. Alprazolam, Alprostadil, Biotene artificial saliva spray, Buproprion,
Cholecalciferol, Folic acid, Hydrochlorothiazide, Hypromellose ophthalmic
solution, Lisinopril, Nicotine patch, Paroxetine, Propranolol, Trazodone,
Plaquenil 200mg twice a day (started January 2013)
II. Pertinent findings
a. Clinical
i. Visual acuity with correction
1. OD: 20/30+1 PH: 20/NI
2. OS: 20/40─1 PH: 20/30
ii. Best corrected acuity from previous visit
1. OD: 20/20─
2. OS: 20/25
iii. Amsler grid: left third of grid is blurred out OU
iv. Confrontation visual fields: inferior left restriction OU to about 40
degrees from center
v. Pupils/EOMs/Slit lamp examination: Normal OU
vi. Tonometry: OD: 14 OS: 15 with Goldmann applanation
vii. Internal examination:
1. Lens: 2+ Nuclear sclerosis OU
2. Vitreous/Nerve/Vessels/Periphery: Normal OU
3. Macula:
a. OD: diffuse moderate epiretinal membrane with
pseudohole temporal to fovea
b. OS: mild diffuse epiretinal membrane
b. Ancillary testing
i. Humphrey Visual Field 30-2 (first test, unreliable)
1. OD: incomplete nasal hemianopsia, with superior temporal loss,
some absolute defects, ─13.88MD
2. OS: superior altitudinal defect, ─8.74MD
ii. Humphrey Visual Field 30-2 (repeat test, improved reliability)
1. OD: left incomplete homonymous hemianopsia with central
sparing, ─6.82MD
2. OS: left incomplete homonymous hemianopsia with central
sparing, ─6.21MD
c. Radiology studies:
i. CT scan without contrast of head and orbits
1. Large mass within the right parieto-occipital region and an
additional smaller mass within the posterior aspect of the left
parietal lobe. There was surrounding edema and a positive
midline shift, which was urgent due to risk of herniation. Masses
suspicious for metastases based on location and associated
edema.
ii. MR imaging of brain with and without contrast
1. Three (right parieto-occipital, left parietal, left frontal operculum)
intracranial masses with surrounding edema and positive midline
shift. Suspicious for metastatic disease.
iii. Chest CT with contrast
1. Nodule with irregular margins in medial right upper lobe of lung
and five pulmonary nodules in the left lower lobe. Suspicious
paratracheal, subcarinal, and right hilar lymph nodes.
d. Laboratory studies:
i. Lymph node and transbronchial needle aspiration biopsy confirms poorly
differentiated non small cell lung adenocarcinoma with assumed
metastases to brain.
III. Differential diagnosis for initial Optometry case presentation
a. Primary: right sided brain tumor (primary vs. metastatic)
b. Secondary: right sided ischemic vs. hemorrhagic cerebral vascular accident
c. Others: right optic tract/visual pathway intracranial inflammatory lesions
(multiple sclerosis, sarcoidosis, or abscess)
IV. Diagnosis and discussion
a. Metastatic brain tumors
i. Definition: cancer found in the brain whose primary source is elsewhere
in the body
ii. Epidemiology: Twenty-five percent of all cancer patients (13.7M) develop
metastasis vs. twenty percent of non small cell lung cancer (NSCLC)
patients. A total of 170,000 people are diagnosed with brain metastases
every year.
iii. Risk factors for brain metastases in NSCLC: age > 65, high Karnofsky
performance score (functional impairment), the number of brain
metastases, and the number of involved extra cranial organs.
iv. Etiology: Metastases occurs most frequently with lung, breast, and skin
primary tumors and is usually spread hematogenously. NSCLC is the most
common primary cancer in patients with brain metastases.
b. Unique features of this case
i. Patient presented with a vague chief complaint that is often heard in
Optometry practices: “blurred vision in left eye.” He initially
demonstrated a non neurological, unreliable visual field with no other
neurological deficits. As many as 40% of patients with brain metastases
will have no neurological symptoms at the time of diagnosis.
ii. This case demonstrates how critical threshold visual field testing still is,
and how ordering and following up with imaging tests can be the rate
limiting step for initiating treatment. The patient described in this case
had a significant enough midline shift to cause concern for herniation.
This could have occurred spontaneously, causing irreparable damage and
possibly death.
iii. Younger Optometrists have likely not encountered many cases of this life
vs. death significance.
V. Management by Optometry and subspecialties
a. Repeat visual field after initial odd “non neurological” presentation
b. Consultation w/radiology, neurology, and urgent care physician (all in same day),
and subsequently radiation oncologist and pathologist (at inpatient facility)
c. Treatment:
i. Case patient: Intravenous dexamethasone for intracranial edema,
palliative whole brain radiation/adjunct chemotherapy
ii. Treatment outcome: patient is still undergoing radiation and two-drug
platinum based chemotherapy with a positive response. Both he and his
family are in good spirits. Lung nodule is not resectable based off location
just as craniotomy with resection has not been performed due to the
lesions’ size and the patient’s comorbidities; however, that will be
reassessed after the first round of chemotherapy and radiation. PET scan
will also be performed as an outpatient to determine location of other
non imageable metastases.
iii. Optometry follow up: Appropriate repeat visual field testing with low
vision rehabilitation and mobility training pending cancer treatment
outcomes is planned.
d. Literature review/references
i. Weinberg, Jeffrey S. “Management of Lung Cancer, Breast Cancer, and
Melanoma Metastatic to the Brain.” Tumors of the Brain and Spine. New
York: Springer Science+Business Media, 2007.
ii. Gerdan L, Segedin B, Nagy V, Khoa, M.T., Trang, N.T.,.Schild S.E., Rades D.
Brain metastasis from non-small cell lung cancer (NSCLC): Prognostic
importance of the number of involved extracranial organs. Strahlenther
Onkol 2014. 190:64–67. 8 November 2013.
iii. Stewart, David J. “Management of advanced non small cell lung cancer:
front line treatment.” Lung Cancer. New York: Humana, 2010.
iv. Quint L, Tummala S, Brisson L, Francis I, Krupnick A, Kazerooni E,
Iannettoni M, Whyte R, Orringer M,. Distribution of Distant Metastases
From Newly Diagnosed Non-Small Cell Lung Cancer. Ann Thorac Surg
1996; 62:246-50.
v. Halasz L, Weeks J, Neville B, Taback N, Punglia R. Use of Stereotactic
Radiosurgery for Brain Metastases From Non-Small Cell Lung Cancer in
the United States. Int J Radiation Oncol Biol Phys 2013; 85:109-116.
vi. Evangelopoulos M, Evangelopoulos D, Potagas C, Sfagos C. Homonymous
hemianopsia as the leading symptom of a tumor like demyelinating
lesion: a case report. Cases Journal 2009; 2:9366.
vii. Kanski, Jack J. Clinical Ophthalmology: A Systematic Approach.
Butterworth-Heineman; 7th edition. 2011.
viii. Gerstenblith, Adam T. et al. The Wills Eye Manual: Office and Emergency
Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and
Wilkins; 6th edition. 2012.
VI. Conclusion
a. Prognosis: in general non small cell lung cancer has a better prognosis than small
cell lung cancer. The actual life expectancy estimate depends on the size and
number of metastasis at time of diagnosis and the number of other organs
involved. A life expectancy was not given for the case patient.
b. Vague visual chief complaints can run the gamut of simple to complex; however,
when basic clinical and physical ocular exam is normal, ordering threshold visual
field testing can give key evidence pointing to the underlying etiology.
c. Visual field deficits can be the only neurological sign indicating intracranial
abnormalities.
d. Prompt follow up with a radiologist and other subspecialists after imaging
studies can prove critical to preserving patient’s quality of life.
e. Optometrists are primary care providers helping diagnose serious, life
threatening diseases while also helping our patients access the more
complicated medical system.
*Comments: Visual fields and CT scan images are available for use in the poster/paper should it
be accepted.