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Sudden Loss Of Vision And Finger Clubbing:
Initial Symptom And Sign Of Bronchogenic Carcinoma
Claus Cursiefen, M.D., Anselm Jünemann, M.D, Ulrich Schönherr, M.D.,
Department of Ophthalmology, University Eye Hospital, Friedrich-Alexander-University
Erlangen-Nürnberg, D-91054 Erlangen, Germany (Chairman and Professor:
G.O.H. Naumann, M.D.)
Claus Cursiefen, M.D., Department of Ophthalmology,
University Eye Hospital, Friedrich-Alexander-University Erlangen-Nürnberg,
Schwabachanlage 6, D-91054 Erlangen, Germany, Tel. *49-9131-8533001,
Fax. *49-9131-8534436,
e-mail: claus.cursiefen@augen.med.uni-erlangen.de
Abstract
Purpose: To report on the association of acute unilateral loss
of vision and finger clubbing.
Methods:Case report. A 52-year-old male patient presented with
acute unilateral loss of vision on OD (light perception). Visual acuity
of the left eye was 20/20. The patient was subjectively healthy. General
examination revealed bilateral finger clubbing.
Results: Ophthalmologic examination and fluorescence angiogram
OU as well as visual field examination on the left side were normal.
Cranial CT and MRT revealed a right supra-/parasellar metastasis compressing
the optic nerve from above. Further examinations demonstrated an yet
unknown large bronchial tumor on the left with secondaries in lung,
liver, adrenal and skin (histology of skin metastasis: adenocarcinoma).
The patient died within six weeks after initial presentation.
Conclusion: Acute unilateral loss of vision associated with
finger clubbing can point to an yet unknown lung carcinoma with metastasis
involving the optic nerve.
Key words: Acute loss of vision - finger clubbing - metastasis
- optic nerve - lung carcinoma
Case report
A 52-year-old welder complained of sudden unilateral loss of vision
overnight. Previously normal visual acuity on OD was light perception
(OS: 20/20). Ophthalmologic history was normal. There were no morphological
alterations of the right eye with exception of mild macular RPE-irregularities
(Fig. 1).
The optic nerve head appeared normal (Fig. 2)
The examination of the other eye including visual field was normal,
as were orbital ultrasound and fluorescence angiogram OU. General medical
history was unremarkable except for mild hypertonus and smoking (30
pack years).General physical examination revealed finger clubbing (Fig.
3, 4)
 
CCT and MRT displayed a supra-/parasellar tumor involving the right
optic nerve (Fig. 5)
and two other cranial tumors. Chest X-ray and CT demonstrated a large
bronchial tumor on the left (Fig. 6)
with secondaries in lung, mediastinum, adrenal, liver and skin of
the back dorsal to body of thoracic vertebra 12 (histology of skin metastasis:
undifferentiated adenocarcinoma). With general physical condition deteriorating
rapidly, the patient died within six weeks after initial presentation
without definitive histology from bronchoscopy. Permission for autopsy
was not granted.
Comment
Ocular metastatic carcinoma occurs in 12 % of patients with extraocular
carcinoma with primary tumor usually involving breast (40 %) or lung
(30 %; Bloch & Gartner 1971; Fery & Font 1974). An isolated optic nerve
metastasis is rare (1.3 % in 227 patients with carcinoma metastatic
to the eye/orbit; Fery & Font 1974). Ocular symptoms caused by an optic
nerve metastasis can be presenting signs of a lung tumor (Crawford &
Reese 1969; Kahan et al. 1965). Here, without histopathologic examination
it is unclear whether the tumor affecting the right optic nerve was
a direct optic nerve metastasis or a cranial suprasellar metastasis
involving the optic nerve. If the ocular symptoms are the initial manifestation
of an extraocular carcinoma, primary tumor usually is a bronchial tumor
(68 %; Fery & Font 1974). Clubbing occurs in certain heart, lung and
gastrointestinal diseases or may be idiopathic/hereditary (Isselbacher
et al. 1994). Thirty percent of patients with bronchial carcinoma demonstrate
clubbing, sometimes as the initial sign (Isselbacher et al 1994; Baughman
et al. 1998). Here, finger clubbing in association with sudden unilateral
loss of vision pointed to an yet unknown primary lung cancer with metastasis
involving the optic nerve.
References
| 1 |
Baughman RP, Gunther KL, Buchsbaum JA & Lower EE (1998): Prevalence
of digital clubbing in bronchogenic carcinoma by a new digital index.
Clin Exp Rheumatol 16: 21-26 |
| 2 |
Bloch RS & Gartner S (1971): The incidence of ocular metastatic
carcinoma. Arch Ophthalmol 85: 673-675 |
| 3 |
Crawford JB & Reese GA (1969): Rapid loss of vision - initial
manifestation of bronchogenic carcinoma (a clinicopathologic case
report). Trans Am Acad Ophthalmol Otolaryngol 73: 964-968 |
| 4 |
Fery AP & Font RL (1974): Carcinoma metastatic to the eye and
orbit. Arch Ophthalmol 92: 276-286 |
| 5 |
Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS &
Kasper DL (1994): Harrison's principles of internal medicine, pp
182-183. New York, McGraw-Hill |
| 6 |
Kahan A, Lelek I & Herboly M (1965): Augensymptome als erste Manifestationen
vom Bronchuskarzinom. Klin Monatsbl Augenheilkd 147: 849-857 |
Figures
| Fig. 1 |
Right fundus photography of the 52-year-old patient 5 days after
acute unilateral loss of vision (visual acuity: light perception
with strongly positive relative afferent pupillary defect). Focal
defects of macular pigment epithelium are present. |
| Fig. 2 |
Normal optic disc in the right eye of the patient 5 days after
acute unilateral loss of vision. Unilaterality of visual loss points
against cancer associated retinopathy (CAR; optic disc area: 3.6
mm2). |
| Fig. 3 |
Finger clubbing in the patient with sudden unilateral loss of
vision in OD (smoker for 30 pack years). Note selective bullous
enlargement of distal segments of fingers and nailfold-/nail-angle
> 180° (arrows). |
| Fig. 4 |
Detail of fig. 3: Note clubbed fingers and nicotine staining of
nails (arrows). |
| Fig. 5 |
Cranial CT-scan (axial section after gadolinium-injection). Note
contrast enhancement of a lesion with peripheral hyperdensity and
central hypodensity in the right supra- and parasellar region involving
the optic nerve before its entry into the optic canal (arrows; metastasis).
Two other cranial tumors with contrast enhancement were found in
the right frontobasal area and in the left highparietal cortex.
Cranial magnetic resonance imaging did not provide further information
about the association of supra-/parasellar metastasis and right
optic nerve. |
| Fig. 6 |
CT-scan of the thorax displaying a large left-sided bronchial
tumor (arrows) highly suggestive of adenocarcinoma of the lung.
Secondaries were found in lung, mediastinum, adrenal, liver and
in the skin of the back (histology of skin metastasis: undifferentiated
adenocarcinoma). |
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