Optic Nerve
Head Metastasis
Brenda L. Gallie, MD; John E. Graham, MD,
\s=b\ A case of tumor metastasis from carcinoma of the lung directly to the cribriform plate is described. Retina and optic nerve were involved, but there was no evidence of tumor invasion of the choroid. It is postulated that the original tumor embolus lodged in a cribriform branch of the arterial circle of Zinn or in the central retinal vessels.
(Arch Ophthalmol 93:983-986, 1975)
Metastasis directly
to the optic head has been recorded infrequently, and in only five cases1-5 was the choroid not involved, proving that the metastasis settled in the op¬ tic nerve head and did not spread from adjacent choroid. In a further 11 cases,8'" choroid was involved to a lesser degree than optic nerve head, and it was postulated that the metas¬ tasis had lodged in the optic nerve. As has been noted in choroidal metastases, the most common site of the primary tumor is the breast. In the present case report, the cribriform plate was involved directly with a metastasis from bronchogenic carcinoma of the lung. nerve
REPORT OF A CASE A 49-year-old man complained of a grad¬ ual decrease in vision in the right eye durSubmitted for publication Sept 12, 1973. From the Department of Ophthalmology, University of Toronto, Toronto. Dr. Gallie is now at Memorial Sloan-Kettering Cancer Center, New York. Reprints not available.
FRCS(C); William S. Hunter, MD, FRCS(C)
ing a period of three to four weeks. There was no history of previous ocular problems. Examination showed that visual acuity in the right eye was counting fingers at 2 feet. The anterior segment and intraocular pressure were normal, and the lens and vitreous were clear. Funduscopic examina¬ tion showed an elevated fluffy white lesion temporal to the disc, involving the macular area, that measured 2 disc diameters hori¬ zontally and vertically and was elevated 2 to 3 diopters. Vessels undulated through and over the mass. On fluorescein angiog¬ raphy, the mass obscured the background choroidal pattern, and there was no leak of fluorescein in or around the mass. Further examination revealed that the patient was a heavy smoker with shortness of breath for the last year. In the last few months, he had lost 10 kg (22 lb) weight and his voice had become hoarse. He was admitted to the hospital for further in¬ vestigation. Examination of the chest re¬ vealed bilateral inspiratory and expiratory rhonchi with laryngeal stridor and hoarse¬ ness. Sputum examination and bronchial washings were positive for malignant cells. Tomograms of the left hilum showed a lobulated lesion consistent with carcinoma. Biopsy showed squamous cell carcinoma in the left upper lobe bronchus and peribronchial lymph nodes, which was felt to be inoperable. There was no evidence of other métastases. Radiotherapy of 3,000 rads was supplied to the chest in divided doses over a two-week period. The eye was not irradiated. The patient gained 11 kg (24.3 lb) over the next few months and returned to work, but seven months later the right eye be¬ came acutely painful. The anterior cham¬ ber showed 4+ flare and cells, with severe rubeosis iridis; intraocular pressure was 60
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Hg. The eye was enucleated with 8 of optic nerve attached. At surgery, no involvement of extraocular structures with tumor was noted. The patient returned to work and was admitted three months later with a grand mal seizure. The electroencephalogram showed posterior parietal focal disorder, and the diagnosis of.brain metastasis was made, for which he received 2,000 rads of whole brain irradiation. A chest x-ray film showed widespread tumor. Shortness of breath became severe, and ten months after the patient was first seen, he died. No postmortem examination was performed. mm
mm
PATHOLOGICAL FINDINGS
On gross examination, the right eye measured 26x25.5x24.5 mm, with 8 mm of optic nerve attached. There was no posterior opacity on transillumination. The eye was sec¬ tioned horizontally, showing closure of the anterior chamber angle, poste¬ rior synechiae, and nuclear sclerosis. The vitreous was largely liquified. Cheesy, friable, white material floated in the fluid vitreous and was evident over almost the whole of the posterior pole, obscuring the optic nerve head where the material ap¬
up. The optic nerve sectioned at the globe where its diameter appeared to be increased. Microscopical examination showed corneal epithelial edema, with con¬ gestion of the episcleral vessels at the limbus. The anterior chamber angles were completely occluded by firm fibrovascular synechiae continuous
peared heaped was
Fig 1 .—A, Horizontal section of globe at optic nerve head: ne¬ crosis of tumor and retina is seen over optic nerve head with vi¬ able tumor surrounding a fibrovascular central core. Cribriform plate contains large central vessel partly occluded by tumor (ar¬ row), but rigid framework of cribriform plate remains intact. Optic nerve is filled with tumor (hematoxylin-eosin, original magnificawith a fibrovascular membrane that extended over the whole of the ante¬ rior surface of the iris, causing ectro¬ pion uvea. There were a few chronic inflammatory cells within the iris stroma and the anterior surface of the lens. Patchy atrophy of the lens epithelium, artifactitious rupture of the lens fibers, and very mild vacu¬ olation of the peripheral cortex at the equator were observed. There was some degeneration of the pigmented and nonpigmented ciliary epithelium, with fibrosis of the ciliary processes. The optic disc was completely cov¬ ered by a mound of necrotic eosino¬ philic granular debris displacing the inner limiting membrane approxi¬ mately 3 mm anterior to its usual po¬ sition (Fig 1,A). A few chronic in¬ flammatory cells were found within this debris, and deep within it, a vas¬ cular connective tissue core sur¬ rounded by a rim of healthy tumor cells, branched out from the cribri¬ form plate. This core contained both arterioles and venules, and posteri-
tion
5). , Magnification of area within box In A; metastatic tu¬ (arrow) is growing along Bruch membrane, peeling off retina and pigment epithelium like a carpet (hematoxylin-eosin, original magnification 75). C, Area of retina near equator; tumor cells are infiltrating along inner limiting membrane and extending into vitreous cavity (hematoxylin-eosin, original magnification 80). mor
orly in the cribriform plate, several large vessels were seen partially oc¬ cluded by plump, healthy tumor cells. On either side of the optic nerve head,
the Bruch necrotic retina membrane, replacing and displacing retina away from the optic nerve. The limit of tumor exten¬ sion on Bruch membrane was clearly seen where retina and pigment epi¬ thelium were both rolled back like a carpet by the tumor lying directly on the Bruch membrane (Fig 1,B). Tu¬ mor cells extended on the internal limiting membrane almost to the ora serrata and, in several places, had broken through the inner limiting membrane to be seen lying on the anterior surface of the retina (Fig 1,C). There was compression through¬ out most of the retina of the normal layered structure, with some areas of hemorrhage into the retina. At the equator, tumor cells were growing along a strand of vitreous adherent to retina. There was no evidence of choroidal or scierai invasion by tumor. tumor extended out
over
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Cross sections of the cribriform plate showed very little tumor and maintenance of the structure, yet sec¬ tions of the optic nerve at the globe showed it to be full of tumor, with in¬ vasion of tumor cells into the subarachnoid space in several areas (Fig 2, left). The most proximal sections of the optic nerve were clear of tumor
(Fig 2, right). High-power magnification of the optic nerve showed infiltration by plump cells, with considerable vari¬ ation in nuclear size and shape (Fig
3, left) with mitotic figures present.
Fibrous reaction and gliosis were evident among the cords of the tu¬ mor. The biopsy of the lung primary showed similar cords of irregular dis¬ torted cells, with mitotic figures and variation in nuclear size and shape
(Fig 3, right).
COMMENT
The central retinal artery at the cribriform plate is a known site for emboli to lodge and produce central
Fig 2.—Left, Cross section of distal optic nerve at globe; cords of plump tumor cells have almost completely replaced normal op¬ tic nerve structure, but no invasion into subarachnoid space is observed (hematoxylin-eosin, original magnification 5). Right,
Cross section of proximal optic nerve; no tumor cells are seen, but there is evidence of compression with myelin dissolution and
Fig 3.—Left, Cross section of distal optic nerve; variation In nu¬ clear size and shape and mitotic figures are evident with com¬ pression of nerve fibers and glial hyperplasia (hematoxylin-eosin, original magnification 100). Right, Bronchial biopsy specimen;
cords of similar irregular distorted cells extend into underlying bronchial stroma (hematoxylin-eosin, original magnification
retinal artery occlusion. Several au¬ thors have postulated this as the mechanism of metastasis to the optic nerve head on the basis of clinical his¬ tory and the presence of peripheral retinal atrophy.·'1011"-13 If this were a common situation, more retinal mé¬ tastases, associated with branch arte-
rial the case
slight glial hyperplasia (hematoxylin-eosin, original magnification x5).
X100).
occlusions, would be expected. In literature, there are only four reports of metastatic involve¬
ment of the retina alone,1619 in con¬ trast to the 6% of patients dying of carcinoma found by Bloch20 to have choroidal métastases at the time of
postmortem examination.
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Tumor emboli could reach the crib¬ riform plate by routes other than the central retinal artery. The central col¬ lateral arteries, branches of the cen¬ tral retinal artery, and the cribriform branches of the arterial circle of Zinn feed the optic nerve head. Emboli lodging in these small vessels would
be much smaller than emboli causing central retinal artery occlusion and would be the size of tumor emboli of a few cells. The preponderance of choroidal métastases over retinal mé¬ tastases suggests that the choroidal circulation is much more likely to be involved with tumor emboli than the retinal circulation. Smoleroff and Agatston16 attribute this to the fact that the ciliary artery exits from the ophthalmic artery more obliquely than does the central retinal artery. The clinicopathological picture of cen¬ tral retinal artery occlusion could re¬ sult secondarily from pressure on the central retinal artery and vein by the growing metastasis or from later tu¬ mor invasion of vessels. From the pathologic findings in this case, it is not possible to deter¬ mine whether the original embolus lodged in a central retinal vessel or in a small branch of the arterial circle of Zinn, feeding the optic nerve head. In commenting on a case of optic nerve involvement,21 Algernon B. Reese suggested that rigidity of the cribri¬ form plate prevents tumor growth in this region, and in this case, the tu¬ mor has spread anteriorly along the central retinal vessels and posteriorly between optic nerve fibers, compress¬ ing and destroying them. The cribri¬ form plate itself is scarcely involved. Because the large bulk of tumor grew over the disc, this suggests that the central vessels were originally in¬ tact, but when the central vessels be-
compromised, the bulk of tumor Only tumor cells im¬ mediately adjacent to new vessels or came
became necrotic.
close to the choroidal circulation could maintain viability. Loss of vision was gradual as the tumor enlarged; this also suggests that the initial tumor embolus was not associated with cen¬ tral retinal vessel occlusion. The present case represents metas¬ tasis to the cribriform plate, with ex¬ tension of the tumor posteriorly into the optic nerve and anteriorly into the retina. Anterior extension on the nerve fiber layer was only a few cells thick but as the tumor spread along Bruch membrane, peeling off the ret¬ ina and pigment epithelium, visual acuity gradually diminished. The bulk of tumor overlying the optic disc and choroid was visible on fundus exami¬ nation and blocked choroidal fluores¬ cence. Eventually, this mass of tumor became necrotic, and rubeosis devel¬ oped with anterior chamber angle clo¬ sure. Acute glaucoma necessitated enucleation of the eye.
References 1. Schiess-Gemuseus, Roth M: Metastatisches Sarcom der Papile und angrenzenden Retina. Graefe Arch Ophthalmol 25:177-192, 1879. 2. Heine L: Sarkom Metastase auf der Sehnervenpapille: Klinisch und Pathologish-anatomish. Klin Monatsbl Augenheilkd 37:326-331, 1899. 3. Ballantyne AJ: A case of metastatic sarcoma of optic nerve and retina. Trans Ophthalmol Soc UK 26:111-122, 1906. 4. Arisawa U: \l=U"\berKarzinom in der Retina.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/08/2015
Klin Monatsbl Augenheilkd 17:386-399, 1914. 5. Norton HJ: Adenocarcinoma metastatic to the distal nerve and optic disc: A stereographic clinicopathologic analysis. Am J Ophthalmol 47:195-199, 1959. 6. Uhthoff W: Zur Lehre von dem metastatischen Carcinom der Choroides. Int Beitr Wissensch Med Festschr R Virchow Berl 2:423-455, 1891. 7. von Haselberg W: Metastatic carcinoma of the optic nerve. Berl Klin Wuchenschr 51:1237\x=req-\ 1238, 1914. 8. Behr C: Metastatische Karzinose der Choroidea und des Sehnerven. Klin Monatsbl Augenheilkd 69:788-799, 1922. 9. Bork K: Carcinom metastase im orbitalen Abschnitt des sehnerven. Virchows Arch Pathol Anat 275:812-815, 1930. 10. Davis WT: Metastatic carcinoma of the optic disk. Arch Ophthalmol 8:226-237, 1932. 11. Van Wien S, Schoch D: Bilateral metastatic carcinoma to choroid and optic nerves. Am J Ophthalmol 43:723-730, 1957. 12. Cherington FJ: Metastatic adenocarcinoma of the optic nerve head and adjacent retina. Br J Ophthalmol 45:229-230, 1961. 13. Nicholls JVV: Metastatic carcinoma of the optic nerve: Report of two cases. Trans Canad Ophthalmol Soc 24:18-30, 1961. 14. Ring HG: Pancreatic carcinoma with metastasis to the optic nerve. Arch Ophthalmol 77:798-800, 1967. 15. Zappia RJ, Smith ME, Gay AJ: Prostatic carcinoma metastatic to optic nerve and choroid. Arch Ophthalmol 87:642-645, 1972. 16. Smoleroff JW, Agatston SA: Metastatic carcinoma of the retina: Report of a case, with pathologic observations. Arch Ophthalmol 12:359-365, 1934. 17. Kennedy RJ, Rummel WD, McCarthy JL, et al: Metastatic carcinoma of the retina. Arch Ophthalmol 60:12-18, 1958. 18. Duke JR, Walsh FB: Metastatic carcinoma of the retina. Am J Ophthalmol 47:44-48, 1959. 19. Flindall RJ, Fleming KO: Metastatic tumor of the retina. Canad J Ophthalmol 2:130-132, 1967. 20. Bloch RS, Gartner S: The incidence of ocular metastatic carcinoma. Arch Ophthalmol 85:673-675, 1971. 21. McDannald CE, Payne BF: Metastatic carcinoma of the optic nerve and choroid. Arch Ophthalmol 12:86-92, 1934.
Head Metastasis
Brenda L. Gallie, MD; John E. Graham, MD,
\s=b\ A case of tumor metastasis from carcinoma of the lung directly to the cribriform plate is described. Retina and optic nerve were involved, but there was no evidence of tumor invasion of the choroid. It is postulated that the original tumor embolus lodged in a cribriform branch of the arterial circle of Zinn or in the central retinal vessels.
(Arch Ophthalmol 93:983-986, 1975)
Metastasis directly
to the optic head has been recorded infrequently, and in only five cases1-5 was the choroid not involved, proving that the metastasis settled in the op¬ tic nerve head and did not spread from adjacent choroid. In a further 11 cases,8'" choroid was involved to a lesser degree than optic nerve head, and it was postulated that the metas¬ tasis had lodged in the optic nerve. As has been noted in choroidal metastases, the most common site of the primary tumor is the breast. In the present case report, the cribriform plate was involved directly with a metastasis from bronchogenic carcinoma of the lung. nerve
REPORT OF A CASE A 49-year-old man complained of a grad¬ ual decrease in vision in the right eye durSubmitted for publication Sept 12, 1973. From the Department of Ophthalmology, University of Toronto, Toronto. Dr. Gallie is now at Memorial Sloan-Kettering Cancer Center, New York. Reprints not available.
FRCS(C); William S. Hunter, MD, FRCS(C)
ing a period of three to four weeks. There was no history of previous ocular problems. Examination showed that visual acuity in the right eye was counting fingers at 2 feet. The anterior segment and intraocular pressure were normal, and the lens and vitreous were clear. Funduscopic examina¬ tion showed an elevated fluffy white lesion temporal to the disc, involving the macular area, that measured 2 disc diameters hori¬ zontally and vertically and was elevated 2 to 3 diopters. Vessels undulated through and over the mass. On fluorescein angiog¬ raphy, the mass obscured the background choroidal pattern, and there was no leak of fluorescein in or around the mass. Further examination revealed that the patient was a heavy smoker with shortness of breath for the last year. In the last few months, he had lost 10 kg (22 lb) weight and his voice had become hoarse. He was admitted to the hospital for further in¬ vestigation. Examination of the chest re¬ vealed bilateral inspiratory and expiratory rhonchi with laryngeal stridor and hoarse¬ ness. Sputum examination and bronchial washings were positive for malignant cells. Tomograms of the left hilum showed a lobulated lesion consistent with carcinoma. Biopsy showed squamous cell carcinoma in the left upper lobe bronchus and peribronchial lymph nodes, which was felt to be inoperable. There was no evidence of other métastases. Radiotherapy of 3,000 rads was supplied to the chest in divided doses over a two-week period. The eye was not irradiated. The patient gained 11 kg (24.3 lb) over the next few months and returned to work, but seven months later the right eye be¬ came acutely painful. The anterior cham¬ ber showed 4+ flare and cells, with severe rubeosis iridis; intraocular pressure was 60
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/08/2015
Hg. The eye was enucleated with 8 of optic nerve attached. At surgery, no involvement of extraocular structures with tumor was noted. The patient returned to work and was admitted three months later with a grand mal seizure. The electroencephalogram showed posterior parietal focal disorder, and the diagnosis of.brain metastasis was made, for which he received 2,000 rads of whole brain irradiation. A chest x-ray film showed widespread tumor. Shortness of breath became severe, and ten months after the patient was first seen, he died. No postmortem examination was performed. mm
mm
PATHOLOGICAL FINDINGS
On gross examination, the right eye measured 26x25.5x24.5 mm, with 8 mm of optic nerve attached. There was no posterior opacity on transillumination. The eye was sec¬ tioned horizontally, showing closure of the anterior chamber angle, poste¬ rior synechiae, and nuclear sclerosis. The vitreous was largely liquified. Cheesy, friable, white material floated in the fluid vitreous and was evident over almost the whole of the posterior pole, obscuring the optic nerve head where the material ap¬
up. The optic nerve sectioned at the globe where its diameter appeared to be increased. Microscopical examination showed corneal epithelial edema, with con¬ gestion of the episcleral vessels at the limbus. The anterior chamber angles were completely occluded by firm fibrovascular synechiae continuous
peared heaped was
Fig 1 .—A, Horizontal section of globe at optic nerve head: ne¬ crosis of tumor and retina is seen over optic nerve head with vi¬ able tumor surrounding a fibrovascular central core. Cribriform plate contains large central vessel partly occluded by tumor (ar¬ row), but rigid framework of cribriform plate remains intact. Optic nerve is filled with tumor (hematoxylin-eosin, original magnificawith a fibrovascular membrane that extended over the whole of the ante¬ rior surface of the iris, causing ectro¬ pion uvea. There were a few chronic inflammatory cells within the iris stroma and the anterior surface of the lens. Patchy atrophy of the lens epithelium, artifactitious rupture of the lens fibers, and very mild vacu¬ olation of the peripheral cortex at the equator were observed. There was some degeneration of the pigmented and nonpigmented ciliary epithelium, with fibrosis of the ciliary processes. The optic disc was completely cov¬ ered by a mound of necrotic eosino¬ philic granular debris displacing the inner limiting membrane approxi¬ mately 3 mm anterior to its usual po¬ sition (Fig 1,A). A few chronic in¬ flammatory cells were found within this debris, and deep within it, a vas¬ cular connective tissue core sur¬ rounded by a rim of healthy tumor cells, branched out from the cribri¬ form plate. This core contained both arterioles and venules, and posteri-
tion
5). , Magnification of area within box In A; metastatic tu¬ (arrow) is growing along Bruch membrane, peeling off retina and pigment epithelium like a carpet (hematoxylin-eosin, original magnification 75). C, Area of retina near equator; tumor cells are infiltrating along inner limiting membrane and extending into vitreous cavity (hematoxylin-eosin, original magnification 80). mor
orly in the cribriform plate, several large vessels were seen partially oc¬ cluded by plump, healthy tumor cells. On either side of the optic nerve head,
the Bruch necrotic retina membrane, replacing and displacing retina away from the optic nerve. The limit of tumor exten¬ sion on Bruch membrane was clearly seen where retina and pigment epi¬ thelium were both rolled back like a carpet by the tumor lying directly on the Bruch membrane (Fig 1,B). Tu¬ mor cells extended on the internal limiting membrane almost to the ora serrata and, in several places, had broken through the inner limiting membrane to be seen lying on the anterior surface of the retina (Fig 1,C). There was compression through¬ out most of the retina of the normal layered structure, with some areas of hemorrhage into the retina. At the equator, tumor cells were growing along a strand of vitreous adherent to retina. There was no evidence of choroidal or scierai invasion by tumor. tumor extended out
over
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Cross sections of the cribriform plate showed very little tumor and maintenance of the structure, yet sec¬ tions of the optic nerve at the globe showed it to be full of tumor, with in¬ vasion of tumor cells into the subarachnoid space in several areas (Fig 2, left). The most proximal sections of the optic nerve were clear of tumor
(Fig 2, right). High-power magnification of the optic nerve showed infiltration by plump cells, with considerable vari¬ ation in nuclear size and shape (Fig
3, left) with mitotic figures present.
Fibrous reaction and gliosis were evident among the cords of the tu¬ mor. The biopsy of the lung primary showed similar cords of irregular dis¬ torted cells, with mitotic figures and variation in nuclear size and shape
(Fig 3, right).
COMMENT
The central retinal artery at the cribriform plate is a known site for emboli to lodge and produce central
Fig 2.—Left, Cross section of distal optic nerve at globe; cords of plump tumor cells have almost completely replaced normal op¬ tic nerve structure, but no invasion into subarachnoid space is observed (hematoxylin-eosin, original magnification 5). Right,
Cross section of proximal optic nerve; no tumor cells are seen, but there is evidence of compression with myelin dissolution and
Fig 3.—Left, Cross section of distal optic nerve; variation In nu¬ clear size and shape and mitotic figures are evident with com¬ pression of nerve fibers and glial hyperplasia (hematoxylin-eosin, original magnification 100). Right, Bronchial biopsy specimen;
cords of similar irregular distorted cells extend into underlying bronchial stroma (hematoxylin-eosin, original magnification
retinal artery occlusion. Several au¬ thors have postulated this as the mechanism of metastasis to the optic nerve head on the basis of clinical his¬ tory and the presence of peripheral retinal atrophy.·'1011"-13 If this were a common situation, more retinal mé¬ tastases, associated with branch arte-
rial the case
slight glial hyperplasia (hematoxylin-eosin, original magnification x5).
X100).
occlusions, would be expected. In literature, there are only four reports of metastatic involve¬
ment of the retina alone,1619 in con¬ trast to the 6% of patients dying of carcinoma found by Bloch20 to have choroidal métastases at the time of
postmortem examination.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/08/2015
Tumor emboli could reach the crib¬ riform plate by routes other than the central retinal artery. The central col¬ lateral arteries, branches of the cen¬ tral retinal artery, and the cribriform branches of the arterial circle of Zinn feed the optic nerve head. Emboli lodging in these small vessels would
be much smaller than emboli causing central retinal artery occlusion and would be the size of tumor emboli of a few cells. The preponderance of choroidal métastases over retinal mé¬ tastases suggests that the choroidal circulation is much more likely to be involved with tumor emboli than the retinal circulation. Smoleroff and Agatston16 attribute this to the fact that the ciliary artery exits from the ophthalmic artery more obliquely than does the central retinal artery. The clinicopathological picture of cen¬ tral retinal artery occlusion could re¬ sult secondarily from pressure on the central retinal artery and vein by the growing metastasis or from later tu¬ mor invasion of vessels. From the pathologic findings in this case, it is not possible to deter¬ mine whether the original embolus lodged in a central retinal vessel or in a small branch of the arterial circle of Zinn, feeding the optic nerve head. In commenting on a case of optic nerve involvement,21 Algernon B. Reese suggested that rigidity of the cribri¬ form plate prevents tumor growth in this region, and in this case, the tu¬ mor has spread anteriorly along the central retinal vessels and posteriorly between optic nerve fibers, compress¬ ing and destroying them. The cribri¬ form plate itself is scarcely involved. Because the large bulk of tumor grew over the disc, this suggests that the central vessels were originally in¬ tact, but when the central vessels be-
compromised, the bulk of tumor Only tumor cells im¬ mediately adjacent to new vessels or came
became necrotic.
close to the choroidal circulation could maintain viability. Loss of vision was gradual as the tumor enlarged; this also suggests that the initial tumor embolus was not associated with cen¬ tral retinal vessel occlusion. The present case represents metas¬ tasis to the cribriform plate, with ex¬ tension of the tumor posteriorly into the optic nerve and anteriorly into the retina. Anterior extension on the nerve fiber layer was only a few cells thick but as the tumor spread along Bruch membrane, peeling off the ret¬ ina and pigment epithelium, visual acuity gradually diminished. The bulk of tumor overlying the optic disc and choroid was visible on fundus exami¬ nation and blocked choroidal fluores¬ cence. Eventually, this mass of tumor became necrotic, and rubeosis devel¬ oped with anterior chamber angle clo¬ sure. Acute glaucoma necessitated enucleation of the eye.
References 1. Schiess-Gemuseus, Roth M: Metastatisches Sarcom der Papile und angrenzenden Retina. Graefe Arch Ophthalmol 25:177-192, 1879. 2. Heine L: Sarkom Metastase auf der Sehnervenpapille: Klinisch und Pathologish-anatomish. Klin Monatsbl Augenheilkd 37:326-331, 1899. 3. Ballantyne AJ: A case of metastatic sarcoma of optic nerve and retina. Trans Ophthalmol Soc UK 26:111-122, 1906. 4. Arisawa U: \l=U"\berKarzinom in der Retina.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/08/2015
Klin Monatsbl Augenheilkd 17:386-399, 1914. 5. Norton HJ: Adenocarcinoma metastatic to the distal nerve and optic disc: A stereographic clinicopathologic analysis. Am J Ophthalmol 47:195-199, 1959. 6. Uhthoff W: Zur Lehre von dem metastatischen Carcinom der Choroides. Int Beitr Wissensch Med Festschr R Virchow Berl 2:423-455, 1891. 7. von Haselberg W: Metastatic carcinoma of the optic nerve. Berl Klin Wuchenschr 51:1237\x=req-\ 1238, 1914. 8. Behr C: Metastatische Karzinose der Choroidea und des Sehnerven. Klin Monatsbl Augenheilkd 69:788-799, 1922. 9. Bork K: Carcinom metastase im orbitalen Abschnitt des sehnerven. Virchows Arch Pathol Anat 275:812-815, 1930. 10. Davis WT: Metastatic carcinoma of the optic disk. Arch Ophthalmol 8:226-237, 1932. 11. Van Wien S, Schoch D: Bilateral metastatic carcinoma to choroid and optic nerves. Am J Ophthalmol 43:723-730, 1957. 12. Cherington FJ: Metastatic adenocarcinoma of the optic nerve head and adjacent retina. Br J Ophthalmol 45:229-230, 1961. 13. Nicholls JVV: Metastatic carcinoma of the optic nerve: Report of two cases. Trans Canad Ophthalmol Soc 24:18-30, 1961. 14. Ring HG: Pancreatic carcinoma with metastasis to the optic nerve. Arch Ophthalmol 77:798-800, 1967. 15. Zappia RJ, Smith ME, Gay AJ: Prostatic carcinoma metastatic to optic nerve and choroid. Arch Ophthalmol 87:642-645, 1972. 16. Smoleroff JW, Agatston SA: Metastatic carcinoma of the retina: Report of a case, with pathologic observations. Arch Ophthalmol 12:359-365, 1934. 17. Kennedy RJ, Rummel WD, McCarthy JL, et al: Metastatic carcinoma of the retina. Arch Ophthalmol 60:12-18, 1958. 18. Duke JR, Walsh FB: Metastatic carcinoma of the retina. Am J Ophthalmol 47:44-48, 1959. 19. Flindall RJ, Fleming KO: Metastatic tumor of the retina. Canad J Ophthalmol 2:130-132, 1967. 20. Bloch RS, Gartner S: The incidence of ocular metastatic carcinoma. Arch Ophthalmol 85:673-675, 1971. 21. McDannald CE, Payne BF: Metastatic carcinoma of the optic nerve and choroid. Arch Ophthalmol 12:86-92, 1934.
