An unusual case of bilateral visual loss from metastatic lung cancer.

A 61 year-old male coffee farmer presented with a history of gradual loss of vision of two years duration in his right eye. He also had a one-week history of swelling and tenderness of the right eye and gradual, painless visual loss in the left eye. There was a six-month history of intermittent fever, nausea, night sweats, anorexia, weight loss and constipation. He did not smoke nor had any chest complaints. He had no light perception and saw no hand movements in the right and left eyes respectively. The right eye had upper lid oedema, proptosis and an external ophthalmoplegia. He had a shallow anterior chamber with inflammatory cells, a mid-dilated unreactive pupil, nuclear sclerosis and a dense vitritis which obscured the fundal view. Examination of his left eye revealed nuclear sclerosis, vitritis and multiple choroidal lesions with overlying ‘bonespicule’ like hyperpigmentation of the inferior retina associated with an exudative retinal detachment. Intraocular pressures were 34 mmHg (right eye) and 11 mmHg (left eye). B-scan ultrasonography of the right eye revealed dense vitritis and multiple areas of choroidal thickening (Fig. 1). He was assessed as a right orbital cellulitis, glaucoma and bilateral uveitis (masquerade syndrome). He was commenced on systemic and topical antibiotics and anti-glaucoma therapy with improvement of the cellulitis and glaucoma; however, his vision remained unchanged. His haemoglobin was 14.7 g/dL, WBC 6.7 X 109/L and ESR 20 mm/hr (Westergren). Vitreous biopsy of the left eye revealed a few atypical mature lymphocytes. The magnetic resonance imaging (MRI) of the brain and orbits revealed areas of choroidal thickening in both eyes (Fig. 2). Computed TomoCASE REPORTS