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A Case of Progressive Dimming Vision.

A man in his early 70s with 2 months of progressive dimming of his vision was referred for evaluation. He initially presented to his primary care physician reporting unintentional weight loss, fevers, and subacute visual decline. Subsequent ophthalmic examination revealed mild anterior and posterior inflammation, raising suspicion for panuveitis. Results of laboratory tests for sarcoidosis, Lyme disease, and syphilis were negative. However, a right upper lobe lung mass noted on the chest radiograph proved to be T2N2M0 stage III non–small-cell lung cancer on biopsy. On presentation to us, the patient’s visual acuity was 20/150 OD and 20/200 OS, but improved to 20/70 OU with pinhole. He was pseudophakic with bilateral mild anterior chamber inflammation, moderate vitreous haze, and inferior vitreous condensations. The posterior pole demonstrated bilateral diffuse retinal pigment epithelial alterations with a prominent leopard spot pattern and focal choroidal pigmented lesions. Macular subretinal fluid tracked to the inferior periphery in both eyes (Figure 1A). Optical coherence tomography confirmed bilateral subretinal fluid and retinal pigment epithelial irregularity (Figure 1B); nummular hypoautofluorescent lesions were interspersed within areas of hyperautofluorescence on autofluorescence imaging. The optic disc and peripheral vasculature leaked on fluorescein angiography. B-scan ultrasonography also showed diffuse choroidal thickening with focal choroidal thickening consistent with the pigmented choroidal lesions. Ultrasonographic biomicroscopy revealed ciliary cysts associated with anterior thickening of both ciliary bodies.