Paraneoplastic Retinopathy Associated with Metastatic Cutaneous Melanoma of Unknown Primary Site

PARANEOPLASTIC RETINOPATHY ASSOCIATED WITH METASTATIC CUTANEOUS MELANOMA OF UNKNOWN PRIMARY SITE

l 2 l I HA AM KIRATLI , CHARLES E. THIRKILL , SEVGUL BILGI(: , BORA ELDEM YY 1 and ARMAN KE(:ECI Ankara, Turkey and Sacramento, California

SUMMARY features of a patient with this rare syndrome are

Purpose: To describe further the clinical and immuno described here. logical features of cutaneous melanoma-associated retinopathy, which is an infrequent form of paraneo CASE REPORT plastic syndrome. Methods: We studied the salient clinical and immuno A 66-year-old man without any prior systemic or logical aspects of a 66-year-old man with metastatic ocular problems presented with the complaint of cutaneous melanoma to lymph nodes of unknown mild visual loss of recent onset in his left eye. He had primary site who developed melanoma-associated experienced occasional flashing lights but had no retinopathy. difficulty with night vision. A few days earlier an Results: There was gradual loss of vision in the left eye. incisional biopsy had been done from his right Colour vision and night vision were not affected. Visual axillary region, where rapid enlargement of four or fields showed arcuate defects. A full-field electroretino five lymph nodes each measuring 3 X 2 X 2 cm was gram demonstrated attenuation of the b-wave ampli noticed. tude in the left eye. The a-wave was intact. Indirect His best corrected visual acuity was 6/9 in the right immunofluorescence techniques showed that the anti eye and 6/18 in the left eye. There was no afferent body reactions took place mainly in the outer plexiform pupillary defect. Results of colour vision testing on layer of the retina. the Lanthony 40 hue test were normal. Slit lamp Conclusions: Bipolar cells seem to be the target in examination and ophthalmoscopy of both eyes were melanoma-associated retinopathy. Contrary to previous unremarkable. Central 30° automated perimetry reports, night blindness may not be a universal finding. showed arcuate defects in the inferior and superior quadrants in both eyes, more pronounced in the left Paraneoplastic retinopathy associated with cuta eye (Fig. 1). Intravenous fluorescein angiography neous melanoma, or melanoma-associated retinopa showed normal prefilling and transit phases in both thy (MAR) syndrome, is a recently recognised cause eyes. In the recirculation phase, a few areas of retinal of various visual disturbances in patients afflicted pigment epithelial (RPE) window defects were with skin melanoma in the absence of metastases to discernible in both maculae. The late phase of the intraocular structures or posterior visual pathways. study was unremarkable. Full-field ERG demon This disorder is characterised by sudden onset of strated that the amplitude of the b-wave from the left night blindness, sensation of pulsating lights, central eye was attenuated below 3 standard deviations of visual field defects and b-wave abnormalities in the our laboratory normals. The a-wave was preserved. electroretinogram (ERG).1,2 The exact causative The implicit times of the components of the ERG were normal. ERG recordings of the right eye were factors for these symptoms and findings are still within normal limits. Magnetic resonance imaging largely unknown. The clinical and immunological (MRI) of the orbits and head was normal. l From: Department of Ophthalmology, Hacettepe School of Meanwhile, histopathological examination of the 2 Medicine, Ankara, Turkey; University of California, Davis excised lymph nodes showed metastatic melanoma. Ophthalmology Research, Sacramento, California, USA. An extensive investigation failed to reveal the Correspondence to: Hayyam Kiratli, MD, Hacettepe University, G6z ABD Slhhiye 06100, Ankara, Turkey. Fax: primary site. The patient was then begun on a (90-312) 309 4101. chemotherapy regimen. Six months later his systemic

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Fig. 1. (a) Automated perimetry of the lefteye showing inferior and superior arcuate visual field defects. (b) Less extensive inferior and superior arcuate defects are observed in the right visual field. MELANOMA-ASSOCIATED RETINOPATHY 891

(a) (b) Fig. 2. (a) Photomicrograph of a section of rhesus monkey eye showing that the antibody interactions are confined to the outer plexiform layer (arrows) located between the inner and outer nuclear layers, the anatomical site of axons and dendrites of bipolar and amacrine cells. (b) Comparison control showing lack of any comparable antibody reactions in normal human serum evaluated at a dilution of 1:100 using indirect immunofluorescence. status was stable and there was no change in his neoplasia can be profound, and could include retinal visual function and other ocular findings. toxicity, interest has come to focus on the unusual His serum was sent to the Thirkill Laboratory at immunological reactions these patients manifest. the University of California Davis Ophthalmology One specific subgroup, those with the cancer 6 Research, where it was evaluated for antibody associated retinopathy (CAR) syndrome, are iden reactions with retinal cells by indirect immunofluor tified by their autoantibody reactions with the escence. This sample serum was prepared before the 23 kDa photoreceptor protein 'recoverin'? This patient received chemotherapy. The serum was substance is a calcium binding protein found in 6 evaluated at a dilution of 1 :400 using 6 /-lm sections certain cells of the retina. To date, this immuno of formalin-fixed, paraffin-embedded rhesus monkey logical grouping of retinopathy patients, based upon eyes and fluorescein-conjugated, goat anti-human an expression of hypersensitivity to a solitary retinal polyvalent immunoglobulins. The autoantibody reac protein, is the only example of a defined form of tions were localised on cellular elements found in the vision loss linked with a single, recognised auto s outer plexiform layer lying between the inner and antigen. outer nuclear layers of the retina (Fig. 2). We found that the principal region of antibody binding was the outer plexiform layer and, to a lesser DISCUSSION extent, part of the inner nuclear layer of the retina . There are various types of paraneoplastic retino The outer plexiform layer contains in its outer two pathy reported in the literature, all resulting from the thirds the axons of photoreceptor rods and cones, remote effects of different forms of cancer, involving enveloped byMUller cell outer segments.9 The inner distinct cell layers of the retina, without intraretinal one-third of this layer is truly plexiform and the 3 5 metastases. - Although the biochemical effects of major components here are the intertwining den- 892 H. KIRATLI ET AL. drites of bipolar cells with the axons of amacrine and different clinical expressions and aspects of the horizontal cells.9 This layer of axons and dendrites disease will be elucidated. lies very close to bipolar cells of the inner nuclear layer.9 Our immunological findings are in agreement This work was supported in part by NEI EYO 9063 the University of California Tobacco-Related Disease with those previously reported byMilam et al.lO and Research Program and Research to Prevent Blindness. Weinstein et ae in their evaluations of the autoanti body content of patients with melanoma-associated Key words: Cutaneous melanoma, Paraneoplastic syndrome, Retina, Melanoma-associated retinopathy. retinopathy, the MAR syndrome. These investiga tors specifically implicate retinal bipolar cells in the autoantibody reactions of MAR patients, but the REFERENCES identity of the retinal antigen(s) involved remains 1. Weinstein JM, Kelman SE, Bresnick GH, Kornguth unknown. 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Grunwald GB, Kornguth SE, Towfighi J, Sassani J, Simmonds MA, Housman CM, Papadopoulos N. found to function normallyY Hypothetically, this Autoimmune basis for visual paraneoplastic syndrome selective involvement of different subsets of bipolar in patients with small cell lung carcinoma: retinal cells may play a role in various clinical manifestations immune deposits and ablation of retinal ganglion cells. ofMAR. Cancer 1987;60:780-6. In MAR syndrome, patients almost invariably 5. Sawyer RA, Selhorst JB, Zimmerman LE, Hoyt WF. Blindness caused by photoreceptor degeneration as a present with acute onset of night blindness, visual remote effect of cancer. Am J Ophthalmol 1976; loss and a sensation of shimmering lights.1,2,10-13 The 81:606-13. night blindness is reported to be severe and 6. Thirkill CEo Cancer associated retinopathy, the CAR permanent? Temporal asymmetry of involvement syndrome. Neuro-ophthalmcilogy1994;14:297-323. between the eyes is a recognised feature of the 7. Thirkill CE, Tait RC, Tyler NK, Roth AM, Keltner JL. The cancer-associated retinopathy antigen is a disease?,l0 recoverin-like protein. Invest Ophthalmol Vis Sci Interestingly, all the latients reported in the 1992;33:2768-72. literature are men.1,2,lO-1 Visual symptoms usually 8. Gery I, Chanaud NP, Anglade E. Recoverin is highly developed 2-4 years after the diagnosis of cutaneous uveitogenic in Lewis rats. Invest Ophthalmol Vis Sci melanoma? Except for the case reported by Rush,12 1994;35:3342-5. 9. Fine B, Yanoff M. Ocular histology: a text and atlas. all the patients had a known primary melanoma site. 2nd ed. New York: Harper and Row, 1979:82-93. Acute Vogt-Koyanagi-Harada like syndrome has 10. Milam AH, Saari JC, Jacobson SG, Lubinski WP, et al. been reported in a patient with metastatic cutaneous Autoantibodies against retinal bipolar cells in cuta melanoma.1s However, unlike MAR, where the neous melanoma associated retinopathy. Invest ERG a-wave usually remains unchanged, that patient Ophthalmol Vis Sci 1993;34:91-100. 11. Alexander KR, Fishman GA, Peachy NS, Marchese had markedly diminished ERG a- and b-waves. AL, Tso MOM. 'On' response defect in paraneoplastic Our patient differs slightly from those previously night blindness with cutaneous malignant melanoma. described in that he did not experience night Invest Ophthalmol Vis Sci 1992;33:447-83. blindness, either at the onset of his disease or during 12. Rush JA. Paraneoplastic retinopathy in malignant his follow-up after chemotherapy. Furthermore, his melanoma. Am J OphthalmoI1993;115:390-1. 13. Berson EL, Lessel S. Paraneoplastic night blindness visual disturbances coincided with the discovery of with malignant melanoma. Am J OphthalmoI1988;106: metastatic melanoma, the primary site of which could 307-11. not be determined. 14. Ripps H, Carr RE, Siegel 1M, Greenstein Vc. 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