Peripheral retinal nonperfusion associated with chronic myeloid leukemia

Delayed manifestation of proliferative retinopathy associated with chronic myeloid leukemia

Purpose

This report highlights a rare case of delayed manifestation of proliferative retinopathy associated with chronic myeloid leukemia (CML) during remission.

Observations

Case report and review of the literature; In this case report, we outline the delayed manifestation and clinical progression of proliferative retinopathy in a 52-year-old male patient with a history of CML diagnosed in 2001. Initially, the patient presented with a white blood cell count (WBC) of 402,200/μl, and the leukocytosis persisted until 2005. Thereafter, the patient remained in remission for over 15 years without any visual complaints until 2022. At that time, the patient sought medical attention due to a ten-day history of left eye visual impairment, leading to the discovery of peripheral neovascularization in both eyes and vitreous hemorrhage in the left eye during fundus examination. The WBC count at the time of presentation to the Emergency Department was 10,460/μl. The patient was treated with fluorescein angiography guided panretinal photocoagulation to the areas of ischemic retina. Subsequent follow-up after eight months demonstrated regression of neovascularization.

Conclusions and Importance

Our findings highlight the occurrence of proliferative retinopathy in the context of CML, uniquely manifesting during remission. This case emphasizes the importance of ophthalmological assessments not only at the time of CML diagnosis but also during subsequent follow-ups, recognizing the potential for delayed presentation of ocular complications.

Detection of Retinal Microvascular Changes with Optical Coherence Tomography Angiography in Patients with Acute Leukemia Without Retinopathy

INTRODUCTION

Acute leukemia often affects microcirculation perfusion. This study aimed to investigate retinal microvascular changes in patients with acute leukemia without retinopathy during clinical remission using optical coherence tomography angiography (OCTA) and to determine the correlation of these changes with systemic laboratory values.

METHODS

Thirty-eight patients in remission from acute leukemia with no retinopathy (NLR group) and 36 age-matched healthy individuals (control group) were included in this cross-sectional study. OCTA parameters, including the central foveal thickness (CFT), foveal avascular zone (FAZ) area, FAZ perimeter, acircularity index (AI), foveal density (FD300), and the vessel densities (VDs) of the superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris were analyzed in a 6 × 6 mm2 macular scan. Correlation and multiple linear regression analyses were conducted to identify potential systemic characteristics associated with these OCTA metrics.

RESULTS

AI (P = 0.034) and FD300 (P < 0.001) differed significantly between the NLR and control groups. The VD of SCP in the parafovea (P = 0.001) and of DCP in both the parafovea (P = 0.011) and perifovea (P = 0.001) were significantly lower in the NLR group than in the control group. In a multiple linear regression analysis, the reduced VD of the perifoveal DCP was significantly correlated with the increased international normalized ratio (standardized beta [STD β] = - 0.356; P = 0.047).

CONCLUSIONS

Macular microvascular changes can be observed during remission from acute leukemia antecedent to clinically visible retinal lesions. Hematological disturbances may be associated with microvascular impairments in preclinical leukemic retinopathy.

Ophthalmologic manifestations as the initial presentation of chronic myeloid leukemia: A review

The presentation of chronic myeloid leukemia (CML) can be variable and related to the phase of the disease. It can manifest a wide range of symptoms and signs; ocular involvement is reported in patients with leukemia at the time of diagnosis. We describe ophthalmic manifestations as an initial presentation in patients with CML. We identified 38 publications between 1971 and 2020 describing ocular manifestations in CML. Ophthalmic problems occur either from direct or indirect infiltration of neoplastic cells or from secondary causes. Although nearly all ocular structures may be affected, leukemic retinopathy is the most frequent clinical manifestation. Others include iris infiltration, anterior uveitis, hypopyon, exudative/serous retinal detachment, and optic nerve infiltration.

Unilateral Macular Choroidal Neovascularization; a Rare Manifestation in Chronic Myelogenous Leukemia

Purpose:

To report a case of chronic myelogenous leukemia (CML) treatment with imatinib mesylate in the remission phase who developed unilateral macular choroidal neovascularization (CNV).

Methods:

A 45-year-old male marketer with a 5-year history of CML treated with imatinib mesylate presented with 2 months history of progressive vision loss and metamorphopsia in the right eye.

Results:

Fundus examination of the right eye revealed grey-white elevated retinal lesion with indistinct borders in the macula and retinal telangiectasia in the temporal macula. Fluorescein angiography (FA) and optical coherence tomography angiography (OCTA) confirmed the presence of CNV in the right eye. After treatment with anti-vascular endothelial growth factor (anti-VEGF), macular CNV regressed significantly.

Conclusion:

Macular CNV must be kept in mind as a rare ophthalmic manifestation of patients with CML under treatment with imatinib even in the remission phase.

Ophthalmologic Manifestations as Initial Presentation of Patients with Chronic Myeloid Leukemia: Report of Two Cases

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm, classically described as triphasic disease (chronic, accelerated, and blast). Despite the significant efforts made by different groups to optimize treatment and outcome, there are still unmet needs and unanswered questions. Ophthalmologic manifestations are among the therapeutic challenges. The best available therapy for patients presenting with ophthalmologic manifestations is still unclear. Here we present two cases of CML (chronic phase) with ophthalmologic manifestations as initial presentation, trying to shed light on this important type of presentation and proposing recommendations for hematologists in view of the current literature.

An unusual association of Morning Glory Syndrome with chronic myeloid leukemia-Philadelphia chromosome

Morning glory disc anomaly (MGDA) is a rare congenital malformation that results from the incomplete formation of the optic nerve in utero. The majority of the patients have unilateral involvement and poor vision leading to sensory strabismus. Morning Glory Syndrome (MGS) may be a part of other syndromes and systemic abnormalities like transsphenoidal basal encephalocele, midfacial malformations, absent optic chiasma, MoyaMoya syndrome, and renal agenesis. In the present report, we describe a patient with a large disc with an excavated posterior scleral opening with a white glial tuft at the centre. The blood vessels were increased in number and arranged radially from the disc with peripapillary hyperpigmentation in clumps. Funnel-shaped excavation of the posterior globe was also noted on MRI. Associated ocular features were microcornea, nystagmus, esotropia, and systemic features included chronic myeloid leukemia- Philadelphia chromosome (CML-PC) and empty sella turcica. We report an unusual association of MGS with CML-PC.

Chronic myeloid leukaemia accelerates proliferative retinopathy in patients with co-existent diabetes: A risk factor not to be ignored

OBJECTIVE

To describe the retinal imaging characteristics, retinopathy management strategies and visual outcomes in cases of diabetes with chronic myeloid leukaemia.

DESIGN

Retrospective observational study.

PARTICIPANTS

Patients with diabetes and chronic myeloid leukaemia managed at our tertiary eye care centre from January 2015 to December 2017.

METHODS

Detailed ophthalmic and systemic evaluation, treatment and follow-up records were reviewed. The main measures studied were visual acuity, intra-ocular pressure, retinopathy severity, and surgical indications and techniques.

RESULTS

Of the six patients studied, three had diabetes and chronic myeloid leukaemia at presentation, while in three cases chronic myeloid leukaemia was diagnosed following evaluation for proliferative retinopathy. The visual acuity ranged from 20/20 to perception of light. All eyes had marked proliferative retinopathy out of proportion to the exudation. None of the eyes had significant macular oedema. Pan-retinal photocoagulation (10/12, 83.33%), intravitreal anti-vascular endothelial growth factor injection (8/12, 66.67%), vitrectomy (2/12, 16.67%), cataract surgery (2/12, 16.67%) and trabeculectomy followed by cryoablation (2/12, 16.67%) was performed for management of the ocular disease as indicated. Median follow-up was 16.5 months (range: 6-24 months). Final visual acuity ranged from PL to 20/20 with acuity ⩾ 20/100 in eight eyes. Four eyes had advanced optic neuropathy from neovascular glaucoma.

CONCLUSION

Accelerated proliferative retinopathy can be seen in cases of diabetes with chronic myeloid leukaemia at the very initial ophthalmic evaluation. Thus, there is a need to alter screening guidelines for retinopathy in cases of diabetes with chronic myeloid leukaemia. Early detection and aggressive management may help preserve visual acuity in such cases.

Leukostasis retinopathy: An uncommon visual threatening complication of chronic myeloid leukemia with severe hyperleukocytosis - A case report and review of the literature

To describe a rare case of an unusual visual threatening complication of chronic myeloid leukemia (CML). A 21-year-old male visited the hospital complaining of 1-week painless binocular acute visual loss without any other symptoms. The patient was diagnosed with CML. He then received emergent leukapheresis with imatinib treatment, which achieved obvious hematological remission. However, the visual acuity did not recover along with the CML remission and ocular structure relief. CML-related leukostasis could induce severe leukostasis retinopathy. Hematologists and ophthalmologists should pay more attention to this relatively rare and severe complication of CML.

Bilateral proliferative retinopathy in B-cell acute lymphoblastic leukemia

A 4-year-old child with B-cell acute lymphoblastic leukemia presented with vitreous hemorrhage due to proliferative retinopathy in both eyes. Pars plana vitrectomy was performed in both eyes to clear nonresolving vitreous hemorrhage after systemic stabilization. Visual recovery was limited by the disc drag in the right eye and subfoveal exudation in the left eye. Etiopathogenesis and management of proliferative retinopathy in acute leukemias are discussed.

Non-invasive imaging of retinal blood flow in myeloproliferative neoplasms

PURPOSE

To study the circulation in the retinal vessels in patients with blood dyscrasia due to myeloproliferative neoplasms using non-invasive retinal imaging.

METHODS

Prospective consecutive case series of seven treatment-naïve patients with chronic myeloid leukaemia (n = 2), polycythemia vera (n = 4), essential thrombocytosis (n = 1) examined before and after cytoreductive treatment. We investigated retinal circulation with motion-contrast imaging, retinal oximetry and spectral-domain optical coherence tomography.

RESULTS

Retinal venous blood velocity increased by 8.14% (CI₉₅ 3.67% to 12.6%, p = 0.004) and retinal arterial oxygen saturation increased by 7.23% (CI₉₅ 2.9% to 11.6%, p = 0.010) at follow-up (mean 12 weeks, range 5-14 weeks) where complete haematological remission had been achieved by cytoreductive treatment. Abnormal optical coherence tomography reflectivity patterns were present at baseline in patients with chronic myeloid leukaemia and were replaced by normal patterns at follow-up. Retinopathy, in the form of cotton-wool spots and retinal haemorrhages, was found at presentation in the two patients with chronic myeloid leukaemia and in one patient with polycythemia vera. The retinopathy had resolved at follow-up in all patients.

CONCLUSION

With non-invasive retinal imaging, we were able to demonstrate increased retinal venous blood velocity, increased retinal arterial blood oxygenation and normalization of intravascular reflectivity patterns after successful treatment of myeloproliferative neoplasms. Larger prospective studies are needed to assess the prognostic value of these non-invasive imaging methods in predicting circulatory complications in myeloproliferative neoplasms.

Chronic Myeloid Leukaemia Presenting as Bilateral Retinal Haemorrhages with Multiple Retinal Infiltrates

Chronic Myeloid Leukaemia (CML) causes retinopathy manifesting as venous dilation and tortuosity, perivascular sheathing, retinal haemorrhages, microaneurysms, cotton-wool spots and optic nerve infiltration. Retina is the most commonly involved intraocular structure in CML. However, retinal involvement is a rare form of presentation of CML and few cases have been reported. We report a case of CML presenting as unilateral sudden visual loss. Fundus showed multiple white centered retinal haemorrhages in both eyes with unilateral macular oedema. Blood work-up showed raised WBC count, high platelet count and low Haemoglobin. Cytological analysis of bone marrow biopsy confirmed Philadelphia chromosome. After a course of Imatinib, visual acuity improved and haemorrhages resolved with normalization of macular thickness. In our case, patient presented early, leading to early detection producing better visual prognosis. This highlights the importance of detailed hematological work up in patients with retinal involvement to rule out leukaemic retinopathy.

A case of leukemic retinopathy mimicking common ischemic retinopathies

Reported case of leukemic retinopathy mimicking common ischemic retinopathies in a young adult where ophthalmic visit was the first step to the diagnosis of chronic myeloid leukemia. It highlights the importance of routine eye exams and that clinicians should suspect leukemia in an otherwise healthy patient presenting with ischemic retinopathy.

Leucapheresis for management of retinopathy in chronic myeloid leukaemia

Chronic myeloid leukaemia is a myeloproliferative neoplasm characterised by granulocytic hyperplasia in the bone marrow and the presence of a specific cytogenetic abnormality known as Philadelphia chromosome with fusion of breakpoint cluster region (BCR) and ableson (ABL) genes. Retinopathy is a rare sight-threatening complication of chronic myeloid leukaemia, which occurs due to leucostasis in retinal blood vessels. We report a case of a patient who presented with visual impairment due to leucostasis, who was successfully managed by leucapheresis along with BCR-ABL tyrosine kinase inhibitor.

Bilateral proliferative retinopathy as the initial presentation of chronic myeloid leukemia

The authors report a rare case of a 48-year-old male with chronic myeloid leukemia (CML) who initially presented with a bilateral proliferative retinopathy. The patient complained of recent visual loss and floaters in both eyes (BE). Ophthalmologic evaluation revealed a best corrected visual acuity (BCVA) of 20/50 in the right eye and 20/200 in the left eye (LE). Fundoscopy showed the presence of bilateral peripheral capillary dropout with multiple retinal sea fan neovascularisations, which were confirmed on fluorescein angiography. Full blood count revealed hyperleukocytosis, thrombocytosis, anemia, and hyperuricemia. Bone marrow aspiration and biopsy showed the reciprocal chromosomal translocation t (9;22), diagnostic of CML. The patient was started on hydroxyurea, allopurinol and imatinib mesylate. He received bilateral panretinal laser photocoagulation and a vitrectomy was performed in the LE. The patient has been in complete hematologic, cytogenetic, and major molecular remission while on imatinib and his BCVA is 20/25 in BE.