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Jessica O’Neil, O.D. ABSTRACT: Regression of metastatic tumor to the choroid, involving the macula, found in an asymptomatic 66 year old female concurrently being treated for breast cancer by mastectomy and chemotherapy. No further treatment necessary at this time. I. Case History -66 year old, white female -Presented for consult for retinal lesion OS -No known ocular history; last DFE was over 5 yrs ago -Patient currently being treated for breast cancer post mastectomy. -Patient currently taking Femara 2.5 mg, Motrin 400 mg, and Zometa 4mg/5ml II. Pertinent findings -Corrected VA- OD 20/25+1 OS 20/25 -No APD -EOMS- full and smooth -Confrontation fields FTFC -Color vision 7/7 OU -IOP 15 mmHg OU -Amsler Grid- Normal OU -DFE Vitreous OD PVD, OS Clear CD .25/.25 OU Maculae OD clear, OS 4DD white lesion with Large RPE clumping- NO fluid, exudates, hemorrhages, CNMV, lipofusin or drusen Vessels WNL OU Periphery OD inferior arcade 1.5DD choroidal hypo-pigmentation (window defect), OS clear B-scan no elevation-WNL OU FLANG- no leakage OU III. Differential Diagnosis -Primary dx- Metastatic tumor -Others- Macular degeneration, exudative retinal detachment, RPE detachment, amelanotic choroidal melanoma, choroidal detachment, retinoblastoma, choroidal osteoma, acute chorioretinitis, retinal vascular occlusive disease. IV. Diagnosis and Discussion -A regressing metastatic tumor was found in the left eye of this patient. Testing in office revealed no elevation, nor leakage of the tumor. Pigment in retina is due to disruption of the RPE from the tumor growth and will likely remain as current presentation. Patient was diagnosed with stage 4 breast cancer in November of 2007. She reports not being able to leave her bed and dementia soon after her diagnosis. After only a couple of months on a new medication for cancer, she reports regaining awareness as well as walking abilities. Patient has been taking Femara for the past eight months with great success. She has not undergone any other chemotherapy or radiation; only the new FDA approved oral medication called Femara. Femara is an aromatase inhibitor that blocks aromatase from converting androgens into estrogen. Estrogen is needed for some tissues (including tumor tissue) to survive. Inhibiting the estrogen will shrink the tumors relying on it to proliferate. Patient reports repeated total body CT scans show no progression of the cancer and our testing shows likely regression of the metastatic tumor. Disruption of the RPE, give this lesion a unique presentation. At first glance, one might assume a retinal degeneration is to blame. With lack of atrophy, hemorrhage, exudates, inflammation, or detachment, it is clear to see that the disruption is due to a once active tumor. Prior medical history is key to diagnosis of this lesion. The two most likely cancers to metastasize to the eye are breast and lung cancer. The breast is the most common primary site for 87.5% of all uveal metastases (Soysal). The malignant emboli reach the choroid by traveling through the short posterior ciliary arteries and travel to the posterior pole (Michaelson). The metastases may occur in either the choroids or the retina with both eyes being affected in about 1/3 of the time (Michaelson). Mean survival time to death after ocular diagnosis was 17 months in a study of metastatic tumors of the uvea conducted by Hulya Soysal, M.D. V. Treatment, Management -At this time, no treatment is necessary. Patient’s current use of Femara is key to keeping the cancer from proliferating and spreading. Patient will keep future appointments with her oncologist and will be monitored by her optometrist with dilated fundus exams, and b-scans for elevation or proliferation of the tumor. Literature shows that first choice treatment for metastatic tumors are chemotherapy and hormonal therapy for disseminated disease, and external beam radiation therapy (EBRT) for those that do not respond to initial treatment (Soysal). Proton beam irradiation is proven to be very effective against metastatic tumors of the choroid. Tsina et. al., reported that 84% of radiation treated tumors regressed completely in five months of treatment. None of these reoccurred. Enucleation is not required in nearly all cases. VI. Conclusion -When evaluating retinal lesions, medical histories are very informative and necessary for diagnosis of many ocular diseases. Ancillary testing is necessary to help properly diagnose and treat these malignant lesions. Prompt treatment is key to regain vision and prevent further proliferation of these tumors. Being diagnosed with these lesions does not necessarily mean losing one’s vision, but can mean a chance to extend one’s life.