A 54-year-old Asian-Indian female, case of ductal carcinoma of the left breast (stage 4, CT2N3CM1) with secondary metastasis to lung and liver, presented with sudden bilateral loss of vision for the past 10 days. She was treated with the 2nd cycle of palliative chemotherapy 2 weeks ago with doxorubicin (70 mg) and cyclophosphamide (700 mg).
Corrected visual acuity in both eyes was finger counting close to face. The fundus examination showed an ill-defined patch of retinal whitening and dot-blot retinal hemorrhages at the macula in both eyes [Fig. 1a and b]. Box-carring of blood column was noted in both eyes. Fundus fluorescein angiography showed enlarged and irregular foveal avascular zone and macular vascular filling defects in both eyes [Fig. 1c and d]. Spectral-domain optical coherence tomography showed inner retinal hyperreflectivity and outer retinal edema in both eyes, more prominent in the left eye [Fig. 1e and f]. A diagnosis of bilateral macular infarction was made.
Laboratory testing revealed normal blood counts except anaemia (haemoglobin 8.8 g/dL), normal fasting blood glucose, blood pressure, and anti-nuclear antibody profile. Due to a lack of other underlying diseases, a hypercoagulable state from metastatic carcinoma was suspected.
Macular infarction occurs due to non-perfusion of the macular capillary bed. Bilateral macular infarction is a very unusual presentation, not previously reported in patients with breast carcinoma. Retinal venous and arterial occlusions have been previously reported with breast carcinoma. The risk of thromboembolism increases with metastasis. Anticancer therapy (chemotherapy such as Platinum-based agents, tyrosine kinase inhibitors, taxanes, hormone therapy, and less commonly cyclophosphamide) may significantly increase the risk by similar mechanisms. No definitive treatment has been proven in the treatment of macular infarction and the visual prognosis remains dismal. Early diagnosis and treatment in lines of retinal arterial occlusion may be of benefit in such cases.
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