Unusual Autofluorescence in a Case of Cancer Associated Retinopathy (CAR)

Abstract

Purpose: : To describe an unusual case of CAR with dual ocular and neoplastic pathology and unique autofluorescence imaging.

Methods: : A 59 year old Caucasian hypermetropic female presented with a sudden onset of ‘haloes’, photopsia and nyctalopia. This had followed a "viral illness". Visual acuity was 20/40 right and 20/30 left with normal intraocular pressures. She had occludable aqueous drainage angles and a diagnosis of angle-closure with intermittent symptoms was made. She underwent YAG laser peripheral iridotomy and subsequent argon laser iridoplasty bilaterally. However, although angle width increased, her symptoms worsened. She was noted to have bilateral cystoid macula edema (CME) and medical retina work-up commenced.

Results: : Visual fields were constricted bilaterally (R>L) with healthy optic discs. ERGs were grossly abnormal in the RE, moderately abnormal in the LE involving both rod and cone systems at a photoreceptor level. Autofluorescence images (AF) demonstrated bilateral petalloid appearance of CME, but also unusual irregular patchy darkening in the left eye. Contrary to clinical experience and expectation, the ‘dark’ areas of the AF image corresponded with preserved retinal function as demonstrated by visual fields and multifocal ERG. Intensive systemic questioning revealed unexplained vaginal bleeding. Further investigation revealed an endometrial carcinoma which was removed and histologically shown to be both a mixed small cell and endometrial carcinoma. She is now undergoing chemotherapy and radiotherapy.

Conclusions: : This case illustrates the difficulty of identifying rare causes of ophthalmic symptoms in the presence of dual ophthalmic pathology. The electrophysiology and autofluorescence were instrumental in reaching a diagnosis. To our knowledge, the AF images are unique; the finding that the dark areas in the AF corresponded to areas of better function, suggests that interpretation of AF imaging may be more complex than previously thought.

Keywords: CAR • imaging methods (CT, FA, ICG, MRI, OCT, RTA, SLO, ultrasound) • electrophysiology: clinical