A 70-year-old male smoker (1 pack a day for 40 years) presented in April 2014 with painless, subacute, bilateral visual decline of 1 month's duration. His past medical history was unremarkable; however, weight loss of 17 kg in recent months as well as myalgia and fatigue were noted.
Examination revealed a bilateral best corrected visual acuity of 20/30. There was no color vision loss. The intraocular pressure values were within the normal range in both eyes. While the anterior chamber was quiet, mild to moderate vitritis was observed in both eyes. Despite the mildly hazy view, indirect ophthalmoscopy yielded no change in the posterior segments (Fig. 1 a-h). A fluorescein angiogram revealed no abnormality (Fig. 1 e, f).
Optical coherence tomography images displayed normal foveal architecture with a few hyper-reflective dots in the posterior vitreous of both eyes corresponding to the vitreous cells (Fig. 1 g, h). The initial diagnosis was bilateral intermediate uveitis.
A full systemic and laboratory work-up was performed in collaboration with a rheumatologist and pulmonologist. Lab investigations included a complete blood count; analysis of serum liver enzymes, renal function, electrolytes, inflammatory markers (erythrocyte sedimentation rate, C-reactive protein), angiotensin-converting enzyme, and rheumatological markers (antinuclear antibody, antineutrophil cytoplasmic antibodies, and rheumatoid factor); infection screening (syphilis and tuberculosis); brain magnetic resonance imaging; and chest radiography. Treatment with 40 mg oral prednisolone was initiated once an infectious etiology was excluded. Finally, positron emission tomography (PET-CT) scanning was used to explore the possibility of sarcoidosis or malignancy.
The PET-CT images revealed an increased uptake of 2-(fluorine-18)-fluoro-2-deoxy-D-glucose in area of the hilar and mediastinal lymph nodes (Fig. 2). To determine the nature of the primary tumor, a biopsy was performed during a bronchoscopy. SCLC (T2N3M0) was established the histopathological examination. The patient was then referred to an oncologist for additional treatment.
After 2 weeks of oral steroid therapy, a subsequent examination yielded a visual acuity of 20/20 and very little lingering bilateral haze (Fig. 3). The patient began a course of chemotherapy, and oral steroid treatment was tapered and terminated. The final diagnosis was bilateral paraneoplastic vitritis. No further visual symptoms were reported during follow-up. Unfortunately, the patient passed away in 2019.