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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.