gravis, and motor neuron degeneration. Ocular paraneoplastic syndromes include optic neuritis, external ophthalmoplegia, and retinal disease [39]. Retinal paraneoplastic syndromes consist of carcinoma-associated retinopathy (CAR), melanoma-associated retinopathy (MAR), acquired cone dysfunction, bilateral diffuse uveal melanocytic proliferation (BDUMP), and paraneoplastic polymorphic vitelliform maculopathy (previously termed Vogt-Koyanagi- Harada (VKH)-like syndrome). Breast cancer can produce CAR and BDUMP. In CAR, the patient notes night blindness, photopsia, transient obscuration of vision, ring scotoma, and photophobia. In BDUMP, multiple pigmented and nonpigmented uveal tumors develop along with dilated episcleral vessels, rapid-onset cataract, anterior uveitis, and serous retinal detachment. Treatment for paraneoplastic syndromes with corticosteroids or immune globulin is occasionally helpful.

Diagnostic Evaluation for Ocular Metastasis

A number of ancillary ophthalmic procedures may aid in the diagnosis of metastatic tumors. These include a systemic evaluation, intravenous fluorescein angiography (IVFA), indocyanine green angiography (ICG), ultrasonography (US), optical coherence tomography (OCT), computed tomography (CT), magnetic resonance imaging (MRI), fine-needle aspiration biopsy (FNAB), and surgical biopsy.

Systemic Evaluation

Once a metastatic tumor to the intraocular structures is suspected on the basis of ophthalmic examination, a detailed systemic evaluation is mandatory. The patient’s history may reveal a previous malignancy, which can be helpful in the diagnosis. As mentioned earlier, however, many patients seen by the ophthalmologist have no history of cancer. Initially, if a female patient has a suspected metastatic tumor, breast and lung

examination with appropriate ancillary studies are indicated. In men, the evaluation should be directed initially toward a primary tumor in the lung. If the lung is normal, then gastrointestinal tract, kidney, thyroid, pancreas, and other organs are evaluated.

Fluorescein Angiography

Fluorescein angiography is a method of imaging the vascularity within a choroidal tumor and is sometimes helpful in the diagnosis of a choroidal metastasis [2, 27, 28]. In contrast to choroidal hemangioma and melanoma, most metastatic carcinomas are hypofluorescent in the arterial and early venous phases and show progressive hyperfluorescence in the subsequent phases. Pinpoint foci of hyperfluorescence appear over the tumor in the venous phase and persist into the late angiograms. There may be moderate late hyperfluorescence of serous subretinal fluid related to the metastatic tumor.

Indocyanine Green Angiography

Indocyanine green angiography provides detail of the choroidal vascular pattern. Imaging of choroidal metastases with this technique generally reveals mild hypofluorescence throughout the angiogram, whereas choroidal melanoma shows gradual hyperfluorescence over 5–10 min, and choroidal hemangioma shows bright hyperfluorescence within 1 min [40].

Ultrasonography

Ocular ultrasonography provides resolution within 1 mm and is useful in the diagnosis of intraocular metastasis. A-scan ultrasonography demonstrates a sharp initial spike and moderate internal reflectivity. This is in contrast to malignant melanoma, which usually shows relatively low internal reflectivity. B-scan ultrasonography typically shows a choroidal mass pattern with moderate to high acoustic solidity, overlying subretinal fluid,