Vogt-Koyanagi-Harada disease like presentation in patients with chronic myeloid leukemia

Clinical and imaging strategies for the assessment of the ocular side effects of systemic targeted anti-cancer therapies

Systemic targeted anti-cancer therapies selectively target cancerous cells whilst limiting systemic side effects. The eye however, is a particularly sensitive organ and the expanding use of the newer targeted chemotherapy agents has been associated with multiple ocular side effects. In this review we provide an update of the ocular side effects of the newer targeted chemotherapy agents along with suggested minimum, pragmatic, evidence-based strategies for effective screening or monitoring for potential ocular side effects. This framework is designed to guide oncologists, trial managers, protocol developers and regulatory authorities so that appropriate ophthalmic clinical examinations and non-invasive modern imaging can be requested and commissioned according to a patient's specific treatment.

A CASE OF RHEGMATOGENOUS RETINAL DETACHMENT IN CHRONIC MYELOID LEUKEMIA

PURPOSE

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm characterized by uncontrolled proliferation of granulocytes, caused the BCR-ABL1 fusion gene. While ocular manifestations of CML are rare, the presentations can range from asymptomatic to sudden vision loss. Chronic myeloid leukemia-associated ocular findings that have been reported include retinal hemorrhages, leukemic infiltrates, and optic disc edema, but a rhegmatogenous retinal detachment in the setting of CML has not been described.

METHODS

This was a case report.

RESULTS

A 21-year-old man presented with intermittent vision loss in his right eye, tinnitus in the right ear, and abdominal distension. Workup revealed significant leukocytosis, splenomegaly, and a positive BCR-ABL1 mutation. He was diagnosed with CML and started on systemic therapy. Examination of the right eye revealed a large intraocular mass. After 2 weeks of systemic treatment, the large elevation in the right eye had improved, allowing visualization of diffuse subretinal whitening. At follow-up, a rhegmatogenous retinal detachment secondary to an atrophic hole in an area of prior subretinal infiltrates was noted. He underwent repair with a scleral buckle. Postoperative course was complicated by redetachment with proliferative vitreoretinopathy, which led to an unrepairable detachment, despite multiple surgeries with silicone oil tamponade.

CONCLUSION

Ocular findings related to CML are rare, with the lowest incidence when compared with other leukemias, and are associated with worse outcomes. Posterior segment findings include intraretinal hemorrhages, Roth spots, and retinal infiltrates. This unique case describes a rhegmatogenous retinal detachment in CML retinopathy with an aggressive course and poor anatomical result.

Vogt-Koyanagi-Harada-Like Disease with Loss of Visual Acuity due to Sunitinib Treatment Restored after Switch in Therapy: A Case Report

Introduction

In this paper, we report a case of visual impairment during treatment with sunitinib in a patient with metastatic renal cell carcinoma.

Methods

Retrospective chart review was used.

Case Presentation

We describe a 74-year-old male with metastatic renal cell carcinoma who was treated with sunitinib and experienced severe loss of visual acuity due to serous retinal detachment and intraretinal fluid. Upon discontinuation of sunitinib, the retinal fluid resolved, and visual acuity was restored.

Conclusion

Serous retinal detachment has been described as a side effect of sunitinib use. Discontinuing sunitinib promptly resolved the subretinal fluid collections and restored vision.

Retinal toxicities of systemic anticancer drugs

Newer anticancer drugs have revolutionized cancer treatment in the last decade, but conventional chemotherapy still occupies a central position in many cancers, with combination therapy and newer methods of delivery increasing their efficacy while minimizing toxicities. We discuss the retinal toxicities of anticancer drugs with an emphasis on the mechanism of toxicity. Uveitis is seen with the use of v-raf murine sarcoma viral oncogene homolog B editing anticancer inhibitors as well as immunotherapy. Most of the cases are mild with only anterior uveitis, but severe cases of posterior uveitis, panuveitis, and Vogt-Koyanagi-Harada-like disease may also occur. In the retina, a transient neurosensory detachment is observed in almost all patients on mitogen-activated protein kinase kinase (MEK) inhibitors. Microvasculopathy is often seen with interferon α, but vascular occlusion is a more serious toxicity caused by interferon α and MEK inhibitors. Crystalline retinopathy with or without macular edema may occur with tamoxifen; however, even asymptomatic patients may develop cavitatory spaces seen on optical coherence tomography. A unique macular edema with angiographic silence is characteristic of taxanes. Delayed dark adaptation has been observed with fenretinide. Interestingly, this drug is finding potential application in Stargardt disease and age-related macular degeneration.

Ponatinib Inducing a Panuveitis with Choroidal Effusions and Neurosensory Retinal Detachment in a Patient with Chronic Myeloid Leukaemia

CASE SUMMARY

We present the case of a 50 year old male patient being treated for chronic myeloid leukemia by the tyrosine kinase inhibitor, Ponatinib. After 3 months of treatment, he developed a sight-threatening granulomatous panuveitis in both eyes, with choroidal effusions and neurosensory retinal detachments. Except for a positive interferon-gamma release assay suggesting previous Tuberculosis exposure, all uveitis investigations were normal. Discontinuation of the suspected causative drug led to resolution of signs and a consequent improvement in visual acuity.

CONCLUSION

Ponatinib use may be associated with with a uveitic phenotype that is reminiscent of Harada's disease. We compare and contrast this rare ocular phenomenon with Vogt-Koyanagi-Harada syndrome and discuss a possible immunological basis.

Acute Lymphoblastic Leukemia Presenting as Acute Vogt-Koyanagi-Harada Syndrome

We aimed to describe a case of acute lymphoblastic leukemia (ALL) that initially presented and was managed as Vogt-Koyanagi-Harada syndrome (VKH). A 62-year-old man was referred for vision loss starting 1 week ago. There was no prior systemic or ocular history. Visual acuity was 20/200 in both eyes. Anterior segment exam was also normal in both eyes. On funduscopy, foveal reflex was significantly reduced. On optical coherence tomography, subretinal fluid was evident in both eyes. Fluorescein angiography showed a hypofluorescent area compatible with subretinal fluid and multiple pinpoint hyper- and hypofluorescent dots surrounding the detached retina. After 4 days, we were informed that the patient had been admitted to a general hospital due to spontaneous ecchymosis and melena. On complete blood count, there was a high white cell count, thrombocytopenia, and low hemoglobin concentration with a probable diagnosis of leukemia. On bone marrow biopsy, ALL with B-cell precursor was confirmed. In conclusion, exudative retinal detachment can be a primary presentation of leukemia and/or lymphoma. In atypical VKH or acute central serous chorioretinopathy cases with multiple pinpoint leakages distributed mostly in the periphery of the subretinal fluid area (not randomly scattered throughout the subretinal fluid), we should consider leukemia.

Bilateral serous retinal detachments associated with burkitt lymphoma

Purpose

To report a case of bilateral serous retinal detachments in a patient found to have burkitt lymphoma.

Observations

A patient who presented with bilateral serous retinal detachments and “B” symptoms underwent extensive workup and was found to have burkitt lymphoma. Multiagent chemotherapy was initiated with resolution of the serous retinal detachments and visual recovery occurring in parallel to disease remission.

Conclusions and Importance

Burkitt lymphoma can present with serous retinal detachments and should be included in the differential for a patient with bilateral serous retinal detachments along with Vogt-Koyanagi-Harada syndrome.

Pseudo-inflammatory manifestations of choroidal lymphoma resembling Vogt-Koyanagi-Harada disease: case report based on multimodal imaging

Background

Hematologic malignancies occasionally cause serous retinal detachment (SRD); however, its pathogenesis remains unclear. Here we present the imaging characteristics of metastatic choroidal lymphoma masquerading as Vogt-Koyanagi-Harada (VKH) disease.

Case presentation

A 45-year-old Japanese woman was referred to our clinic because of bilateral SRD with blurred vision. Fluorescein angiography revealed multiple pinpoint leakage followed by pooling OU. Enhanced depth imaging optical coherence tomography showed marked choroidal thickening OU. Laser speckle flowgraphy detected choroidal circulation impairment OU. Although these results totally agreed with the inflammatory manifestations of acute VKH disease, indocyanine green angiography demonstrated various sizes of sharply marginated hypofluorescent lesions that seemed atypical for the finding of VKH disease, i.e., vaguely marginated hypofluorescent small dots. Cerebrospinal fluid pleocytosis was not detected. Blood tests revealed leukocytosis together with elevation of lactate dehydrogenase and soluble interleukin-2 receptor levels. Corticosteroid pulse therapy did not improve any ocular findings. Bone marrow biopsy was then performed, leading to a definite diagnosis of diffuse large B-cell lymphoma. After starting systemic chemotherapy, both SRD and choroidal thickening resolved rapidly with visual recovery. However, choroidal hypoperfusion persisted, which contrasted distinctly with the inflammatory pattern of VKH disease, i.e., the restoration of choroidal blood flow in parallel with normalization of choroidal thickness.

Conclusions

Our detailed multimodal observations highlighted the differential imaging features of choroidal lymphoma despite close resemblance to VKH disease especially at the initial stage. Impaired circulation in the thickened choroid marked the pseudo-inflammatory pathogenesis of SRD due to choroidal involvement with neoplastic, but not inflammatory cells.