Download Angelina Bonner

Abstract: Renal cell carcinoma has been shown to cause elevated levels of anticardiolipin and
antiphospholipid antibodies. This is a rare case report of disc edema, macular edema, and
hemorrhages secondary to renal cell carcinoma.
I. Case History
Patient Demographics: 63 year old Caucasian male with a history of renal cell
carcinoma, prostate cancer, and lymph cancer
Chief Compliant: Sudden decrease in vision OS which started 3 weeks
Patient denies any pain, but has pressure around O.S.
Ocular History: wears reading glasses only, otherwise unremarkable
Medical History: Renal cell carcinoma, prostate cancer, and lymph cancer
Medication: Tadalafil 20 mg one tablet by mouth every week
II. Pertinent Findings
Visual acuity: 20/30 OD, 20/80 OS; BCVA 20/20 OD, unable to improve BVA OS
Pupils:
PERRLA OD and Trace APD OS
Externals:
Unremarkable
EOM:
Full and smooth OU
IOP:
Normal OU
Slit lamp:
Pinguecula OU
Fundus exam: Unremarkable OD
(+) Grade V disc edema OS with no disc details i.e. obscured vessels
(+) Hemorrhages peripapillary>posterior pole
(+) Macular edema OS
(+) Cotton wool spot on optic nerve head OS
Additional Tests
Humphrey visual field shows a full field OD, and mild central scotoma with inferior
depression in the inferior arcuate area consistent with a RNFL defect OS
OCT shows normal macular thickness OD and significant macular edema with
intraretinal fluid OS
Blood pressure 145/88
Laboratory Studies
Complete serology work up not limited to: CBC, Chem panel, RPR, PT/PTT, Protein S,
Protein C, HgA1c, IgA, IgG, IgM, Lipid panel, Prothrombin factor, RPR, and BETA 2
Glycoprotein AB,ESR, Homocysteine, Anticardiolipin, Antiphospholid, and ANA
CBC shows (+) anemia
Plasma shows high potassium, urea nitrogen, and creatinine; low EGFR
Lipid panel shows high triglyceride, LDL, and cholesterol
IgM levels are elevated
Homocysteine levels are elevated
Protein C levels are elevated
ESR levels are elevated
Neuro-images: CT of the head and orbits without contrast
Mild generalized cerebral atrophy. Focal atrophy in the left frontal lobe is seen. There is
no mass effect on ventricles or chiasm. The paranasal sinuses show mucosal thickening in the
ethmoid sinus suggestive of sinusitis. The orbits are unremarkable and cranium intact.
Fluorescein Angiogram will be utilized to differentiate infiltrative disc edema from renal cell
carcinoma vs. hypercoaguable CRVO associated with renal cell carcinoma.
III. Differential Diagnosis
The differentials include: central retinal vein occlusion secondary to renal cell carcinoma,
infiltrative optic neuropathy secondary to renal cell carcinoma, orbital mass, hypertensive
retinopathy, and retinopathy due to anemia.
IV. Diagnosis
Renal cell carcinoma leading to disc edema, hemorrhages, and macular edema with
subsequent decrease in vision OS.
Discussion
Renal cancer is the 7th most malignant cancer in men in the United States. Renal cell
carcinoma accounts for 85% of all renal cancers, and it arises from the renal epithelium. The
classic triad of renal cell carcinoma includes flank pain, hematuria, and palpable abdominal
mass. Additional signs include weight loss, anemia, and fatigue. Risk factors for renal cell
carcinoma include smoking, obesity, and hypertension. Renal cell carcinoma has been shown to
cause elevated levels of anticardiolipin and antiphospholipid antibodies. Elevation in levels of
antiphospholipid antibodies is classified as antiphospholipid syndrome which is a thrombophillic
disorder where venous or arterial thrombosis may occur. Central retinal vein occlusions have
been linked to hypercoagulability. Additionally, elevated antiphospholipid antibodies have been
found to be more common in patients with CRVO.
V. Treatment and management
It is critical to use appropriate diagnostic testing to determine the underlying cause of the
previous mentioned ocular manifestations for appropriate treatment especially when associated
with systemic cancer, such as renal cell carcinoma. Disc edema is considered a medical
emergency, and proper imaging should be obtained to rule out an orbital mass. Macular edema
secondary to renal cell carcinoma can be managed using anti- VEGF or kenalog injection.
VI. Conclusion
Renal cell carcinoma is a progressive life threatening condition that can cause ocular
manifestations and decreased vision. This case report demonstrates the importance of lab testing
and imaging in managing renal cell carcinoma with associated retinal findings. Eye care
practitioners must be aware of the various mechanisms of ocular manifestations secondary to
renal cell carcinoma.
VII. References
1. Cohen, Herbert and F.J. Mcgovern.2005. Renal Cell Carcinoma. N Engl J Med
353:2477-2490
2. Adrean, S.D. and I.R. Schwab. 2003. Central Retinal Vein occlusion and Renal Cell
Carcinoma. AM J Ophthalmol 136:1185-1186
3. Friedman, Neil and P.K. Kaiser. 2009. The Massachusetts Eye and Ear Infirmary.
Elsevier
4. Galli, Monica. 2004. Antiphospholipid Syndrome Association Between Laboratory
Tests and Clinical Practice. Pathophysiol Haemost Thromb 33:249-255