A 59-YEAR-OLD man noticed shadows in his left eye for 3 weeks. He had no other symptoms or previous ocular disease. Ocular examination findings revealed a visual acuity of 20/20 OD and hand motions OS, a left afferent pupillary defect, and disc edema in the left eye with peripapillary exudates and retinal hemorrhages. The presumed diagnosis was central retinal vein occlusion. One week later, the vision deteriorated to light perception in the left eye, and choroidal folds were noted during the fundus examination (Figure 1). An infiltrative process became the suspected diagnosis. Echographic findings showed marked elevation of the left optic disc (Figure 2). Magnetic resonance imaging demonstrated a thick ring of enhancement encircling the left optic nerve intraorbitally (Figure 3) that extended through the optic canal. The vision of the left eye deteriorated to no light perception within 2 weeks. The results of 2 lumbar punctures revealed 13 lymphocytes in the cerebrospinal fluid; otherwise the findings were normal. Findings from blood tests and computed tomographic scans of the chest, abdomen, and pelvis were unremarkable. Owing to the normal findings on workup for a primary tumor source, an optic nerve sheath biopsy was performed and revealed an adenocarcinoma containing signet ring cells (Figure 4). Results of an upper gastrointestinal tract barium study were suspicious for gastric carcinoma. Radiation therapy to the eye was initiated during investigation for the primary tumor. Endoscopic gastric biopsy confirmed the diagnosis of gastric signet ring cell adenocarcinoma (Figure 5). Funduscopic examination findings 5 weeks later revealed optic atrophy, a few resolving retinal hemorrhages, and choroidal folds (Figure 6). The patient died 2 months later after a course of intrathecal chemotherapy initiated after a lumbar puncture had identified signet ring cells.
Sung JU, Lam BL, Curtin VT, Tse DT. Metastatic Gastric Carcinoma to the Optic Nerve. Arch Ophthalmol. 1998;116(5):692-693. doi:10.1001/archopht.116.5.692