OSLI Retina

July 2020

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July 2020 · Vol. 51, No. 7 417 cancer proposes a "string of sausages" sign with ICGA, as hyperfluorescent choroidal vessels with alternating hypofluorescence from overlying RPE hypertrophy and lipofuscin accumulation. 2 However, our case shows that the alternating fluorescence with ICGA also oc- curs outside the large choroidal vessels. It may more accurately show speckled hypofluorescence from both scattered RPE hyperplasia and infiltrating melanocytes 1 overlying hyperfluorescent choroidal hyperpermeabil- ity, more consistent with an overall "spaghetti and par- mesan" appearance. The ICGA findings are striking and may be helpful in differentiating BDUMP from other conditions. The late staining of the choroid with ICGA not only highlights the permeable, inflamed choroidal vessels, but may correspond with intrastromal fibrin de- position. The abundance of fibrin in our case is particularly interesting. It has been established previously that fibrin is implicated with choroidal hyperpermeability. 14 We believe that the late multifocal staining in the choroid with ICGA can be attributed to the molecular affinity of the ICG molecule upon conjugation with the fibrin. This explanation for the abundance of fibrin may then account for both the BLD described above and staining pattern with ICGA found in this case. The gravitational tract inferiorly in the left eye could suggest an overlapping mechanism with chronic CSCR (known to frequently exhibit gravitational tracks), 6,15 which can further complicate the overlap of presenta- tions with this disease and delay diagnosis or recog- nition of malignancy. Gravitational tracks can also be nonspecific as they are observed in conditions like cho- roidal hemangioma in addition to choroidal neovascu- larization with AMD. 16 To our knowledge, like the BLD, this feature has also not been described previously with BDUMP. It is possible that this gravitating track could have been related to fluid and fibrin within the BLD; further investigation is warranted to determine if the BLD can lead to these gravitating tracks. The presence of drusen (or similar-appearing deposits) implies con- comitant exudative disease, and in this case, consider- ation of neovascular AMD, that can further obscure the correct diagnosis. BDUMP is classically thought to lead to mortality within 1 to 2 years, although survival is reported as long as 9 years. 1 Our case illustrates that despite 5 years of known cancer, and 3 years of eye disease presumably consistent with exudation in the setting of BDUMP, the diagnosis cannot be excluded upon duration alone. Moreover, an association of BDUMP with bladder cancer may confer increased survival relative to other malignancies, though reported numbers remain small. In addition to further characterization of imaging fea- tures, additional investigation is needed for augmenting the prognosis and treatment options for patients with BDUMP and their underlying malignancy. REFERENCES 1. Gass JDM, Gieser RG, Wilkinson CP, Beahm DE, Pautler SE. Bilateral diffuse uveal melanocytic proliferation in patients with occult carcino- ma. Arch Ophthalmol. 1990;108(4):527-533. https://doi.org/10.1001/ archopht.1990.01070060075053 PMID:2322154 2. O'Day R, Michalova K, Campbell WG. Bilateral diffuse uveal melano- cytic proliferation associated with bladder cancer: a novel imaging find- ing. Ophthalmic Surg Lasers Imaging Retina. 2019;50(8):525-528. https:// doi.org/10.3928/23258160-20190806-10 PMID:31415702 3. Fernández-Avellaneda P, Breazzano MP, Fragiotta S, et al. Bacillary layer detachment overlying reduced choriocapillaris flow in acute idiopathic maculopathy. Retin Cases Brief Rep. 2019;Publish Ahead of Print. https:// doi.org/10.1097/ICB.0000000000000943 PMID:31764886 4. Mehta N, Chong J, Tsui E, et al. Presumed foveal bacillary layer detach- ment in a patient with toxoplasmosis chorioretinitis and pachychoroid disease. Retin Cases Brief Rep. 2018;Publish Ahead of Print. https://doi. org/10.1097/ICB.0000000000000817 PMID:30142112 5. Cicinelli MV, Giuffré C, Marchese A, et al. The bacillary detachment in posterior segment ocular diseases. Ophthalmol Retina. 2020;4(4):454- 456. https://doi.org/10.1016/j.oret.2019.12.003 PMID:31937472 6. Mrejen S, Balaratnasingam C, Kaden TR, et al. Long-term visual out- comes and causes of vision loss in chronic central serous chorioretinopa- thy. Ophthalmology. 2019;126(4):576-588. https://doi.org/10.1016/j. ophtha.2018.12.048 PMID:30659849 7. Babu Munipalli S, Yenugu S. Uroplakin expression in the male reproduc- tive tract of rat. Gen Comp Endocrinol. 2019;281:153-163. https://doi. org/10.1016/j.ygcen.2019.06.003 PMID:31181195 8. Alrashidi S, Aziz AA, Krema H. Bilateral diffuse uveal melanocytic pro- liferation: a management dilemma. BMJ Case Rep. 2014;2014(may22 1):2014. https://doi.org/10.1136/bcr-2014-204387 PMID:24855079 9. Klemp K, Kiilgaard JF, Heegaard S, Nørgaard T, Andersen MK, Prause JU. Bilateral diffuse uveal melanocytic proliferation: case report and literature review. Acta Ophthalmol. 2017;95(5):439-445. https://doi. org/10.1111/aos.13481 PMID:28636126 10. Rahimy E, Coffee RE, McCannel TA. Bilateral diffuse uveal melanocytic proliferation as a precursor to multiple systemic malignancies. Semin Ophthalmol. 2015;30(3):206-209. https://doi.org/10.3109/08820538.2 013.835835 PMID:24124896 11. De Salvo G, Prakash P, Rennie CA, Lotery AJ. Long-term sur- vival in a case of bilateral diffuse uveal melanocytic prolifera- tion. Eye (Lond). 2011;25(10):1385-1386. https://doi.org/10.1038/ eye.2011.180 PMID:21799522 12. Martinez Rodriguez RH, Buisan Rueda O, Ibarz L. Bladder cancer: pres- ent and future. Med Clin (Barc). 2017;149(10):449-455. https://doi. org/10.1016/j.medcli.2017.06.009 PMID:28736063 13. Balaratnasingam C, Freund KB, Tan AM, et al. Bullous variant of central serous chorioretinopathy: expansion of phenotypic features using mul- timethod imaging. Ophthalmology. 2016;123(7):1541-1552. https://doi. org/10.1016/j.ophtha.2016.03.017 PMID:27084564 14. Guyer DR, Yannuzzi LA, Slakter JS, Sorenson JA, Ho A, Orlock D. Digi- tal indocyanine green videoangiography of central serous chorioretinopa- thy. Arch Ophthalmol. 1994;112(8):1057-1062. https://doi.org/10.1001/ archopht.1994.01090200063023 PMID:8053819 15. Yannuzzi LA, Shakin JL, Fisher YL, Altomonte MA. Peripheral retinal detachments and retinal pigment epithelial atrophic tracts secondary to central serous pigment epitheliopathy. Ophthalmol- ogy. 1984;91(12):1554-1572. https://doi.org/10.1016/S0161- 6420(84)34117-3 PMID:6084221 16. Eandi CM, Sugin S, Spaide RF. Descending atrophic tracts associated with choroidal hemangioma. Retina. 2005;25(2):216-218. https://doi. org/10.1097/00006982-200502000-00018 PMID:15689816

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