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Muge R. Kesen, MD; Deepak P. Edward, MD; Lawrence J. Ulanski, MD; Howard H. Tessler, MD; Debra A. Goldstein, MD

Arch Ophthalmol. 2008;126(4):572-574.

Uveal metastasis is the most common intraocular malignancy,¹ but iris involvement accounts for only 5% to 10% of cases.^2-3 Most iris metastases are carcinomas, with breast, lung, and gastrointestinal tract carcinomas representing the majority of primary tumors. Renal cell carcinoma is also reported to result in metastasis to the iris.⁴ There is no history of a previously diagnosed primary tumor in 32% of cases.³ We report a case in which an iris lesion led to the detection of lung cancer.

Report of a Case
A 65-year-old white woman noted pain in her left eye, was diagnosed with anterior uveitis, and was treated with topical steroid drops. Two weeks later an iris mass was noted. The mass enlarged during a 2-week period, resulting in her referral to the University of Illinois at Chicago.

Her ocular history was significant for cataract surgery in each eye. Her medical history was significant for chronic obstructive pulmonary disease, with a 50-pack/y smoking history. Work-up prior to referral included normal complete blood cell count findings, negative fluorescent treponemal antibody absorption (FTA-ABS), and normal purified protein derivative findings. Chest radiography revealed minimal scarring in the left lung base.

Visual acuity was 20/20 OU. Slitlamp examination results in the right eye were normal. The left anterior chamber had +3 cells. There was a dome-shaped elevation of the nasal iris with overlying aggregates of cells that had the appearance of mutton-fat keratic precipitates (Figure 1A). The mass measured 4.7 x 3.5 mm and was deep to the anterior stroma. Gonioscopy revealed iris elevation with white cellular aggregates without synechiae (Figure 1B). Fundus examination results were unremarkable. Ultrasound biomicroscopy revealed a solid mass with cystic spaces involving the iris and the ciliary body with overlying aggregates (Figure 1C).

View larger version (65K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 1. Iris mass in the left eye. A, In the left eye, the nasal iris mass deep to the iris stroma with overlying metastatic seeding appearing as pseudokeratic precipitates (arrows). B, Gonioscopy showing the mass and aggregates of tumor cells shed into the angle (arrows). C, Ultrasound biomicroscopy of the iris mass showing the multicystic nature of the mass and the lack of scleral invasion. Arrows indicate cystic spaces within the mass. D, Anterior view of the entire iris mass.

Biopsy of the mass revealed a poorly differentiated small-cell neoplasm with mitotic activity (Figure 2A). Immunohistochemistry showed strong AE1/AE3 (pancytokeratin) immunoreactivity consistent with epithelial origin (eFigure 1). Immunolabeling results with HMB-45, S-100, Mel A, neuron-specific enolase, CD45, CD20, and CD3 were negative.

View larger version (199K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 2. Histopathology. A, Photomicrograph showing the iris stroma replaced by small cells, hyperchromatic nuclei, and scant cytoplasm (hematoxylin-eosin, original magnification x10). Inset, Note mitotic figures within the tumor infiltrate (arrow) (hematoxylin-eosin, original magnification x40). B, Computed tomographic scan showing the left perihilar soft tissue mass (arrow).

A computed tomographic scan of the chest and abdomen revealed multiple pulmonary nodules and a left perihilar soft tissue mass suspicious for malignancy. There were bilateral adrenal masses and multiple soft tissue masses within the mesentery suspicious for metastatic lesions. Complete blood cell count and liver function test results were normal.

Two weeks later the patient developed jaundice. Follow-up computed tomography demonstrated a new mass in the head of the pancreas. Endobronchial biopsy of the left lower lobe mass revealed an undifferentiated small-cell carcinoma (eFigure 2). The patient declined chemotherapy and was lost to follow-up.

Comment
Metastases to the iris may appear as nodules, iridocyclitis, rubeosis iridis, iris atrophy, hypopyon, hyphema, or secondary glaucoma.⁵ Metastatic lesions characteristically appear as grayish white, yellow, orange, or brown, gelatinous, vascularized nodules on the surface of the iris.⁶

This case is unusual in that the initial presentation was uveitis with pseudokeratic precipitates, presumably secondary to tumor shedding. Also, the tumor was within the iris rather than on it. There was no known history of cancer, and chest radiography was read as unremarkable. Diagnosis was made only after biopsy of the iris tumor, which suggested a pulmonary malignancy, and pulmonary lesions were seen on subsequent computed tomography. Retrospective re-review of the chest radiograph revealed no lung nodules; however, fullness of the left hilum was noted. Had this been appreciated earlier, a computed tomographic scan of the chest might have revealed cancer prior to the iris biopsy.

AUTHOR INFORMATION
Correspondence: Dr Goldstein, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, 1855 W Taylor St, M/C 648, Chicago, IL 60612 (debrgold{at}yahoo.com).

Financial Disclosure: None reported.

REFERENCES
1. Nelson CC, Hertzberg BS, Klintworth GK. A histopathologic study of 716 unselected eyes in patients with cancer at the time of death. Am J Ophthalmol. 1983;95(6):788-793. FULL TEXT | ISI | PUBMED 2. Stephens RF, Shields JA. Diagnosis and management of cancer metastatic to the uvea: a study of 70 cases. Ophthalmology. 1979;86(7):1336-1349. ISI | PUBMED 3. Shields JA, Shields CL, Kiratli H, de Potter P. Metastatic tumors to the iris in 40 patients. Am J Ophthalmol. 1995;119(4):422-430. ISI | PUBMED 4. Wyzinski P, Rootman J, Wood W. Simultaneous bilateral iris metastases from renal cell carcinoma. Am J Ophthalmol. 1981;92(2):206-209. ISI | PUBMED 5. de Rivas P , Marti T, Andreu D, Carreras M, Quintana M. Metastatic bronchogenic carcinoma of the iris and ciliary body. Arch Ophthalmol. 1991;109(4):470. FREE FULL TEXT 6. Shields CL, Shields JA, Gross NE, Schwartz GP, Lally SE. Survey of 520 eyes with uveal metastases. Ophthalmology. 1997;104(8):1265-1276. ISI | PUBMED

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