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Correspondence to Dr Vishal Raval, [email protected]
Background
Iris lesions may have varied ocular and systemic aetiology, thereby posing a diagnostic dilemma to clinicians and pathologists. We present a case, describing the differential diagnoses of iris mass lesions, role of multimodal imaging and management of iris metastasis, from primary lung carcinoma.
Case presentation
A man aged 60 years presented with complaints of pain and redness in the right eye of 5 days duration. On examination, his best-corrected visual acuity was 20/40 in both eyes. Slit-lamp examination of the right eye revealed circumciliary congestion with corneal stromal oedema. Anterior chamber had 2+ cells and neovascularisation of the iris at pupillary border. A greyish white irregular nodular mass with surface vascularity, measuring 4×2×1 mm extending from 7 to 9’o clock position arising from the anterior iris surface and reaching up to mid-periphery was noted. The posterior extent of the lesion could not be elicited. Few broad-based posterior synechiae were noted and there was grade 2 nuclear sclerosis. Gonioscopy showed whitish irregular mass originating from the anterior iris surface and extending till anterior part of trabecular meshwork. Intraocular pressure (IOP) measured 22 mm Hg in the right eye and 16 mm Hg in the left eye (Goldmann applanation tonometer). Anterior segment of the left eye was normal. Both eyes fundus examination was unremarkable with normal disc and macula.
Investigations
Slit-lamp photography in diffuse and oblique illumination documented the extent of tumour and presence of surface vascularity (figure 1A and B). Anterior segment optical coherence tomography demonstrated a homogenous solid mass on the anterior iris surface with posterior shadowing (figure 1C and D). Anterior segment fluorescein angiography in the late phase revealed leakage of the dye within the tumour suggestive of highly vascularised tumour and leakage from pupillary border due to neovascularisation (figure 1E). A provisional diagnosis of iris mass lesion, inflammatory or neoplastic, possibly metastatic was considered.
Initial laboratory work revealed leucocytosis (14 400 per cubic millimetre). A high-resolution CT of the chest showed presence of a well-circumscribed lobulated soft tissue dense lesion in the superior and posterior segments of left lower lobe of lung encasing the segmental bronchi. There was presence of consolidation and cavitation, along with scattered multiple satellite nodules in both the lungs. Left hilar and...