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Journal Français d'Ophtalmologie
Volume 37, n° 5
pages e73-e74 (mai 2014)
Doi : 10.1016/j.jfo.2013.06.010
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Incidental ‘early’ diagnosis of colorectal carcinoma by way of central retinal vein occlusion
Un diagnostic « précoce » du cancer colorectal occasionnellement fait à la suite du diagnostic de l’occlusion veineuse rétinienne centrale
 

A. Özkaya
 Beyoglu Eye Training and Research Hospital, Bereketzade Cami Sok., 34421 Beyoglu, Istanbul, Turkey 

Corresponding author.
H.M. Özkaya
 Istanbul University, Faculty of Medicine of Istanbul, Internal Medicine Department, 34093 Capa, Fatih, Istanbul, Turkey 

Z. Alkın, A. Demirok
 Beyoglu Eye Training and Research Hospital, Bereketzade Cami Sok., 34421 Beyoglu, Istanbul, Turkey 

A great number of systemic disorders may be diagnosed for the first time in the patients who are presented with ophthalmologic manifestations [1, 2]. Various ocular findings were identified as the clinical manifestations of different systemic disorders like systemic hypertension, diabetes mellitus, and even systemic neoplasms in previous studies [1, 2]. Awareness of the visual symptoms, ocular findings, laboratory findings may help in the early diagnosis of these conditions and reduce the morbidity and mortality. The patients with eye problems associated with specific laboratory findings and alarm symptoms, should be evaluated in a whole perspective. In this report, we aimed to present a patient who has been incidentally diagnosed to have colorectal carcinoma after being evaluated for central retinal vein occlusion, and iron deficiency anemia which was detected on the laboratory examination.

A seventy-two-year-old male patient presented with the complaint of visual loss in his right eye in February 2012. He had a history of systemic arterial hypertension since 24 years and type 2 diabetes mellitus since 12 years. He was not in good health, and seemed pale. Visual acuity was 20/800 in the right and 20/20 in the left eye. The patient had no significant refractive error. Anterior segment examination revealed a mild relative afferent pupillary defect in the right eye. Intra-ocular pressure was in normal limits. Fundus examination showed numerous retinal hemorrhages and cotton-wool spots in four quadrants, dilated retinal veins, macular edema and severe disc swelling in the right, and a few micro-aneurisms in the left eye. Findus fluoresce in angiography (FIFE) showed leakage from the optic disc, blockage of fluorescence in the areas corresponding to the intraretinal hemorrhages, and capillary drop-out zones in the peripheral retina in the right and several hyperfluorescence spots associated with micro-aneurisms in the left eye. Optical coherence tomography showed macular edema with a central retinal thickness (CRT) of 755 microns in the right, and normal foveal contour with a CRT of 209μm in the left eye. In the light of these findings the patient was diagnosed as central retinal vein occlusion in the right, and non-proliferative diabetic retinopathy in the left eye.

Hematologic tests revealed moderately high blood lipids and high glucose level (208mg/dL; normal range 70–110mg/dL) as well as hypochromic microcytic anemia. The results of blood count were as follows: erythrocyte count 4.2m/mL (normal range 4.3–5.7m/mL); hematocrit 34.1% (normal range 37–51%), hemoglobin 10.5g/dl (normal range 12.5–17.5g/dL) and mean corpuscular volume 74μm3 (normal range 75–97μm3). Serum iron binding capacity was 440μg/dL (normal range 250–410μg/dL) and serum ferritin was 11ng/mL (normal range 30–400ng/mL). Laboratory workup including erythrocyte sedimentation rate, liver function tests, kidney function tests, coagulation tests and urinary analysis were in normal limits. Based on the findings, the patient was diagnosed to have iron deficiency anemia.

The patient received one single intravitreal injection (1.25μg/0.05 cc) of bevacizumab for CRVO related macular edema and prophylactic panretinal laser photocoagulation to the ischemic areas in the peripheral retina.

To investigate the cause of iron deficiency anemia, the patient was questioned for further systemic and medical information. He reported that, since 6 months he suffered from bowel habit change, excessive straining and a sense of incomplete evacuation during defecation; so he took laxatives once a week unless prescribed. There was no history of weight loss and hematochezia; however, he noticed loss of stamina since 2 weeks. Considering the patient had iron deficiency anemia and alarm symptoms (change in bowel habits, new-onset constipation, loss of appetite) he was referred to the gastroenterology department to rule out a possible gastrointestinal malignancy as a source of bleeding and iron loss. In the gastroscopic examination, chronic non-atrophic gastritis was detected. Colonoscopy revealed a tumoral mass in the sigmoid colon. The pathologic evaluation of the mass was consistent with moderately differentiated colon adenocarcinoma. There was neither systemic nor lymphatic metastasis. The patient underwent a laparotomic left colectomy and is still being followed by oncology department. At the patient's 12-months follow-up visit, he was in good health and visual acuity was 20/800 in the right eye with no ocular neovascularization.

Retinal vein occlusion is the second frequent vascular disease of the retina after diabetic retinopathy. The incidence of retinal vein occlusions in population-based studies varies from 2 to 8 per 1000 persons and increases with age [3]. The pathogenesis of CRVO is considered multifactorial [4]. Systemic workup is required especially for the patients who are younger than 50 years old and who do not suffer from the other risk factors. However, basic laboratory work-up including blood count, complete hypercoagulability and thrombotic workup is essential for all of the patients.

Iron deficiency anemia is the most common type of hypochromic microcytic anemia [5], and it is usually seen in young females who are in menstrual ages; however, when it is diagnosed in males, it especially indicates gastrointestinal iron loss. If the patient is older than 75 years old, gastrointestinal malignities should always be kept in mind [6, 7]. Iron deficiency anemia is a very important prognostic factor for early diagnosis of colorectal cancers [6, 7, 8]. Singh et al. [8] reported that iron deficiency anemia is one of the most powerful predictive factor for diagnosis of colorectal carcinoma. So far, early diagnosis of colorectal carcinomas is very important to reduce morbidity and mortality [9]. In addition, diabetes mellitus confers an increased risk of malignancies including the colorectal carcinomas [10].

In this case report, we presented a patient with central retinal vein occlusion who had concomitant iron deficiency anemia due to colorectal carcinoma. The patient was not aware of his systemic problems except hypertension and diabetes mellitus. During ophthalmological and systemic assessment for central retinal vein occlusion his anemia was recognized. Then the diagnosis of anemia led us to the diagnosis of colorectal carcinoma. Interestingly, the central retinal vein occlusion might have saved the patient's life. In conclusion, systemic diseases can present with various clinical signs, and the diagnosis may be time consuming because of a long period up to the full clinical picture. In daily practice, every ophthalmologist faces the patients who have systemic diseases. Evaluation of the medical history, systemic findings and full clinical data of the patients should be part of the examination.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

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