A 79-year-old Caucasian woman developed blurred vision and floaters in her left eye, which progressed over the course of several months. Past ocular history was unremarkable. At the time of initial evaluation by a local retina specialist, she denied having headache, eye pain or photophobia. Examination was notable for dense vitreous cellular reaction in the left eye. The patient received an injection of sub-Tenon’s triamcinolone and was started on topical difluprednate three times daily for presumed inflammatory vitritis with no improvement in her visual acuity. She presented to the Wills Eye Hospital Ocular Oncology Service one month later for a second opinion.
The patient’s past medical history was notable for polymyalgia rheumatica and rheumatoid arthritis (treated with prednisone), atrial fibrillation, hypothyroidism, chronic obstructive pulmonary disease, gastrointestinal reflux disease, hypertension and diverticulitis. She had a complex oncologic history that included colon cancer treated with partial colectomy and chemotherapy 15 years prior and cutaneous malignant melanoma of her back that was locally excised six years earlier. Additionally, she was diagnosed with patch/plaque-stage mycosis fungoides (MF) at age 56 years, which progressed to tumor stage, requiring initiation of systemic therapy and local radiation, though there was never nodal or visceral involvement. Family history was remarkable for multiple cancers among siblings, including gastric, central nervous system, bone and prostate. The patient disclosed a history of prior tobacco use totaling 80 pack-years.
Medications at the time included amlodipine, apixaban, sotalol, diclofenac, fluticasone/salmeterol, levalbuterol, furosemide, levothyroxine, pantoprazole, famotidine, prednisone, bexarotene and alprazolam.
On presentation to Wills, visual acuity was 20/60 in the right eye and CF at 8’ in the left eye. Pupils were equal, round and reactive in each eye. There was no afferent pupillary defect. Extraocular motility was full bilaterally. Intraocular pressure was 12 mmHg OU. Anterior segment evaluation revealed moderate nuclear sclerosis OU. There was 4+ cell noted in the anterior vitreous in the left eye (Figure 1A). On ophthalmoscopic examination bilateral macular drusen were noted (Figure 1B). Fundus examination was otherwise unremarkable in the right eye. Ophthalmoscopic examination of the left eye demonstrated diffuse vitreous opacities with 2+ vitreous haze and without clinically evident retinal, subretinal or choroidal infiltration. A choroidal nevus was documented in the left macula.