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Veerappan Pasricha M, Callaway NF, Nguyen QD, Do DV. Serous retinal detachment as a presenting sign of acute lymphoblastic leukemia: A case report and literature review. Am J Ophthalmol Case Rep 2021; 23:101142. [PMID: 34222714 PMCID: PMC8242964 DOI: 10.1016/j.ajoc.2021.101142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 05/05/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose To describe a unique case of unilateral serous retinal detachment as the presenting sign of B-cell acute lymphoblastic leukemia (ALL). Observations A 74 year old woman presented with right eye blurry vision and was found to have an underlying serous retinal detachment, along with cotton wool spots, inner retinal hemorrhages, and retinal pigment epithelial changes throughout her bilateral fundi. Fluorescein angiography demonstrated bilateral vasculitis and ultrasonography revealed asymmetric thickening and enhancement of the affected eyes’ choroid. This prompted a systemic lab workup and results were suspicious for an underlying hematologic malignancy. The patient was admitted to the hospital for bone marrow biopsy confirming B-cell ALL, underwent intensive intravenous and intrathecal chemotherapy, and was discharged one month later. Follow up appointment in the ophthalmology clinic demonstrated functional and anatomic improvement in the serous retinal detachment and choroidal thickening suggestive of infiltration in her right eye. Conclusions SRDs are an uncommon ocular manifestation of leukemia, and even less common as a presenting sign of the disease. A comprehensive literature review demonstrated 11 other cases reported worldwide. We present the first such case with additional findings of leukemic retinopathy, optic nerve and choroidal infiltration, and vasculitis, as well as a complete library of ophthalmic imaging from the patient's initial presentation. Importance A new diagnosis of serous retinal detachment(s) without any obvious cause should raise suspicion for leukemia and prompt further workup. Early recognition of this hematologic malignancy is crucial for prompt initiation of life-saving therapy.
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Key Words
- /Acronyms: Acute lymphoblastic leukemia, (ALL)
- Acute lymphoblastic leukemia
- Acute lymphocytic leukemia
- Acute lymphoid leukemia
- Central serous chorioretinopathy
- Exudative retinal detachment
- Serous retinal detachment
- autofluorescence, (AF)
- central serous chorioretinopathy, (CSR)
- cotton wool spots, (CWS)
- fluorescein angiogram, (FA)
- intravenous, (IV)
- magnetic resonance imaging, (MRI)
- optical coherence tomography, (OCT)
- retinal pigment epithelium, (RPE)
- serous retinal detachment, (SRD)
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Affiliation(s)
- Malini Veerappan Pasricha
- Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Natalia F Callaway
- Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
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Serous retinal detachment as a sign of leukemic choroidopathy: A systematic review. Surv Ophthalmol 2021; 67:149-167. [PMID: 33933437 DOI: 10.1016/j.survophthal.2021.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/23/2022]
Abstract
Leukemia is a rare disease associated with a high mortality rate. The presence of unilateral or bilateral serous retinal detachment (SRD) as a sign of choroidal infiltration can be one of the manifestations of acute leukemia, both as a primary sign or in a relapse. We consolidated the literature on SRD as a sign of leukemic choroidopathy regarding its epidemiology, clinical manifestations, and main imaging diagnostic tools. Well-documented cases regarding acute lymphoblastic leukemia (ALL), acute myelogenous leukemia (AML), relapsed ALL and relapsed AML published until September, 2020, in peer reviewed journals were included. The literature shows an interesting range of choroidal infiltration cases assessed by modern imaging techniques, such as optical coherence tomography (OCT) with and without enhanced depth imaging (EDI) and fluorescein angiography (FA). These tools allow choroidal assessment and better understanding and characterization of this rare condition. Complete ophthalmological workup should be performed in these patients using both FA and EDI-OCT to assess the choroidal anatomy and integrity. An increase in choroidal thickness measured with EDI-OCT can reveal active disease and potentially diagnose a leukemic relapse promptly.
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Bodhankar P, Balakrishnan D, Basheer N, Gopalakrishnan M, Anantharaman G. Leukemic retinopathy with rare presentation in B-cell acute lymphoblastic leukemia. JOURNAL OF CLINICAL OPHTHALMOLOGY AND RESEARCH 2021. [DOI: 10.4103/jcor.jcor_157_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Adaniya A, Bazterrechea P, Trucco JI, Schlaen BA, Kusminsky G, Saravia MJ. Bilateral macular detachment: Choroid as a sanctuary of acute lymphoblastic leukemia. Am J Ophthalmol Case Rep 2020; 19:100746. [PMID: 32478200 PMCID: PMC7251383 DOI: 10.1016/j.ajoc.2020.100746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 11/05/2022] Open
Abstract
Purpose To describe a bilateral macular detachment as the only sign of acute lymphoblastic leukemia relapse and prompt reversal with total body irradiation without ocular protection. Observations We present the case of a 20-year-old patient, diagnosed with a high-risk phy-negative, pre-B acute lymphoblastic leukemia (ALL), with a positive MLL gene rearrangement. After a Berlin-Frankfurt-Munster-like regimen chemotherapy protocol and a first complete remission, ALL relapse was diagnosed, so he was commenced on a FlaG-Ida protocol (fludarabine, idarubicin, granulocyte-colony stimulating factor, and high-dose cytarabine). He achieved a second complete remission with positive minimal residual disease and was scheduled for urgent allogeneic bone marrow transplant. Five days before the conditioning regimen was initiated, the patient complained of visual loss in the left eye and then in the right eye. Ophthalmological evaluation showed a best corrected visual acuity of the right eye (OD) of 20/100 and of the left eye (OS) of 20/400. Optical coherence tomography (OCT) showed a bilateral serous sub-foveal detachment. The sub-foveal choroidal thickness was measured by enhanced depth imaging (EDI-OCT) and showed a significant increase (OD 836 μm and OS 1036 μm) compared with normal (average 310 μm). This choroidal thickness increase, associated with the serous macular detachment, was interpreted as a choroidal leukemic infiltration. A lumbar puncture with cytologic studies and flow cytometry was performed, showing no evidence of central nervous system (CNS) involvement of leukemia. CNS and orbital magnetic nuclear resonance imaging showed no pathology. No extramedullary involvement could be confirmed. Retinal fluorescein angiography showed multiple and diffuse leakage points (pinpoint pattern) within the macular area. This pattern reinforced our presumptive diagnosis, even though the lumbar puncture and flow cytometry were negative. The hematologist decided to proceed with the bone marrow transplant. A myeloablative conditioning regimen was delivered, based on total body irradiation (TBI) with a total dose of 12 Gy plus fludarabine 30 mg/m2 for five days. No ocular protection was used during TBI. Only 2 h after TBI commenced, the patient reported a significant improvement in his visual acuity. We confirmed 20/20 in both eyes. The OCT showed a dramatic decrease in the choroidal thickness measurement (OD 387 μm and OS 408 μm compared with 836 μm and 1036 μm measured before radiotherapy). Conclusions and importance Complete ophthalmological evaluation and EDI-OCT choroidal thickness measurement could be fundamental tools necessary to determine CNS involvement of ALL, even in cases with negative cerebrospinal fluid and brain imaging.
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Abstract
PURPOSE To demonstrate vitreoretinal traction as a mechanism for perimacular folds in abusive head trauma. METHODS We performed gross and histopathologic examination of eyes of children with suspected abusive head trauma and identified those with typical perimacular folds. Information was collected regarding the incident that led to the child's death and systemic manifestations noted at autopsy. Eyes were prepared in a fashion that allowed for demonstration of the vitreoretinal interface. RESULTS Ten eyes of five patients (2-13 months) were examined. All patients had systemic manifestations of abusive trauma including intracranial injury. All cases provided evidence of vitreoretinal traction producing perimacular folds. Condensed vitreous was seen attached to the apices of the retinal folds, and the detached internal limiting membrane comprising the inner surfaces of the schisis cavity. Four cases showed severe bilateral multilayered symmetric retinal hemorrhages extending to the ora serrata. All cases showed optic nerve sheath subdural hemorrhage and subarachnoid hemorrhage. Orbital hemorrhage was unilateral in two cases and bilateral in three cases. Four cases showed orbital fat hemorrhage. One case showed extraocular muscle sheath and cranial nerve sheath hemorrhage. Two cases showed juxtapapillary intrascleral hemorrhage. CONCLUSION Vitreoretinal traction is the likely mechanism of perimacular folds in abusive head trauma.
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Yabas Kiziloglu O, Mestanoglu M, Totuk Gedar OM, Adiguzel C, Toygar O. Recurrence of acute lymphoblastic leukemia manifesting as serous retinal detachments and optic disc swelling. Int Ophthalmol 2017; 38:1791-1795. [PMID: 28712034 DOI: 10.1007/s10792-017-0648-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/05/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of this case report is to describe a patient with acute lymphoblastic leukemia (ALL) who developed bilateral serous retinal detachments and unilateral optic disc swelling. METHODS A 23-year-old woman with ALL presented to the ophthalmology clinic with bilateral subacute visual loss. RESULTS Ophthalmologic examination revealed bilateral serous retinal detachments and unilateral optic disc swelling. Magnetic resonance imaging for differential diagnosis was inconclusive; however, cerebrospinal fluid sampling demonstrated leukemic involvement of the central nervous system. The patient's vision improved and fundus findings resolved with the institution of systemic and intrathecal chemotherapy. CONCLUSIONS Serous retinal detachment and optic disc swelling are unusual ocular manifestations of ALL. They may occur due to leukemic infiltration of ocular structures and may indicate extramedullary recurrence of the disease. Early recognition and treatment is crucial to improve prognosis.
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Affiliation(s)
- Ozge Yabas Kiziloglu
- Department of Ophthalmology, Faculty of Medicine, Göztepe Medical Park Hospital, Bahcesehir University, E-5 uzeri 23 Nisan sok No: 17 Merdivenkoy, Kadikoy, Istanbul, Turkey.
| | - Mert Mestanoglu
- Faculty of Medicine, Bahcesehir University, Istanbul, Turkey
| | - Ozgun Melike Totuk Gedar
- Department of Ophthalmology, Faculty of Medicine, Göztepe Medical Park Hospital, Bahcesehir University, E-5 uzeri 23 Nisan sok No: 17 Merdivenkoy, Kadikoy, Istanbul, Turkey
| | - Cafer Adiguzel
- Department of Hematology, Faculty of Medicine, Bahcesehir University, E-5 uzeri 23 Nisan sok No: 17 Merdivenkoy, Kadikoy, Istanbul, Turkey
| | - Okan Toygar
- Department of Ophthalmology, Faculty of Medicine, Göztepe Medical Park Hospital, Bahcesehir University, E-5 uzeri 23 Nisan sok No: 17 Merdivenkoy, Kadikoy, Istanbul, Turkey
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Green W, Rao PK, Harocopos GJ. Extramedullary Relapse of Acute Myelogenous Leukemia Presenting as a Large Serous Retinal Detachment. Ocul Oncol Pathol 2016; 3:95-100. [PMID: 28868277 DOI: 10.1159/000450858] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/13/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS To describe the rare presentation of a large, unilateral, serous retinal detachment as an extramedullary manifestation of acute myelogenous leukemia (AML) recurrence without bone marrow or central nervous system involvement after more than 1 year of follow-up. METHODS Case report. RESULTS A teenage patient with AML, previously treated with multiple courses of systemic chemotherapy, radiation, and bone marrow transplant, presented with acute vision loss. Ophthalmic workup revealed a large, unilateral, bullous, serous retinal detachment. Ultimately, he underwent subretinal fluid biopsy, which was found to be positive for leukemic blast cells. Cytologic markers matched his initial bone marrow biopsy, and therefore were diagnostic of extramedullary AML relapse. CONCLUSIONS Leukemia can cause various ophthalmic manifestations. Autopsy studies suggest that choroidal infiltration is relatively common, but clinical progression to serous retinal detachment is quite uncommon. Furthermore, serous retinal detachment is generally shallow, posterior, and much more often reported in acute lymphocytic leukemia. The ophthalmologist plays a critical role in identifying leukemic ocular involvement. This case demonstrates the potential for ocular biopsy to secure the diagnosis of extramedullary relapse in order to initiate prompt treatment and systemic workup.
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Affiliation(s)
- Wesley Green
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - P Kumar Rao
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - George J Harocopos
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
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Palme C, Bechrakis NE, Stattin M, Haas G, Zehetner C. Decreased Vision as Initial Presenting Symptom of Acute Lymphoblastic Leukemia: A Case Report. Case Rep Ophthalmol 2016; 7:377-383. [PMID: 27721787 PMCID: PMC5043257 DOI: 10.1159/000447994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
This case illustrates that hematologic disorders must be considered as a potentially life-threatening cause for vision loss. Proper laboratory workup and timely interdisciplinary approach are essential to ensure the best possible care for ophthalmic patients. Historically, before the use of bone marrow biopsy, the ophthalmologist was often asked to assist in the diagnosis of leukemia. Since ophthalmological symptoms may be the initial presenting signs of leukemia as highlighted in this case, the ophthalmogist is still of crucial importance.
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Affiliation(s)
- Christoph Palme
- Department of Ophthalmology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Martin Stattin
- Department of Ophthalmology, Medical University Innsbruck, Innsbruck, Austria
| | - Gertrud Haas
- Department of Ophthalmology, Medical University Innsbruck, Innsbruck, Austria
| | - Claus Zehetner
- Department of Ophthalmology, Medical University Innsbruck, Innsbruck, Austria
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Patel AV, Miller JB, Nath R, Shih HA, Yoon MK, Freitag SK, Papaliodis G, Chen TC, Eliott D, Kim IK. Unilateral Eye Findings: A Rare Herald of Acute Leukemia. Ocul Oncol Pathol 2016; 2:166-70. [PMID: 27239459 DOI: 10.1159/000442951] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/20/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM Unilateral choroidal infiltration as the initial manifestation of leukemic relapse in adults is rare, particularly after an extended period of remission. This report describes this unique ophthalmic presentation, highlights the associated diagnostic challenges, and reviews the literature. METHODS Two cases are described and an extensive literature review was conducted. RESULTS A 59-year-old male with acute lymphoid leukemia, in remission for 18 months, presented with unilateral scleritis, exudative retinal detachment, and choroidal thickening. A 57-year-old male with a history of acute myeloid leukemia, in remission for 4 years, presented with unilateral choroidal thickening leading to secondary angle closure. In both cases, there was a significant lag from the onset of eye symptoms to establishing a systemic diagnosis of acute leukemia, leading to a delay in definitive systemic treatment, despite a high suspicion of disease based on ophthalmic findings. CONCLUSIONS These two cases illustrate the fundus findings consistent with leukemic choroidal infiltration that can represent the first sign of relapsed leukemia. The successful treatment of these patients hinges on collaboration between ophthalmologists and oncologists to optimize patient outcomes, highlighting the need for both groups to be aware of this rare ophthalmic presentation.
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Affiliation(s)
- Avni V Patel
- Department of Ophthalmology, Harvard Medical School, Boston, Mass., USA
| | - John B Miller
- Department of Ophthalmology, Harvard Medical School, Boston, Mass., USA; Retina Service, Massachusetts Eye and Ear Infirmary, Boston, Mass., USA
| | - Rajneesh Nath
- Department of Hematology/Oncology, UMass Memorial Medical Center and University of Massachusetts Medical School, Worcester, Mass., USA
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass., USA
| | - Michael K Yoon
- Department of Ophthalmology, Harvard Medical School, Boston, Mass., USA; Department of Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Mass., USA
| | - Suzanne K Freitag
- Department of Ophthalmology, Harvard Medical School, Boston, Mass., USA; Department of Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Mass., USA
| | - George Papaliodis
- Department of Ophthalmology, Harvard Medical School, Boston, Mass., USA; Ocular Immunology and Uveitis Service, Massachusetts Eye and Ear Infirmary, Boston, Mass., USA
| | - Teresa C Chen
- Department of Ophthalmology, Harvard Medical School, Boston, Mass., USA; Glaucoma Service, Massachusetts Eye and Ear Infirmary, Boston, Mass., USA
| | - Dean Eliott
- Department of Ophthalmology, Harvard Medical School, Boston, Mass., USA; Retina Service, Massachusetts Eye and Ear Infirmary, Boston, Mass., USA
| | - Ivana K Kim
- Department of Ophthalmology, Harvard Medical School, Boston, Mass., USA; Retina Service, Massachusetts Eye and Ear Infirmary, Boston, Mass., USA
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Bilaterale Sehverschlechterung und zunehmender körperlicher Leistungsverlust. Ophthalmologe 2014; 111:781-4. [DOI: 10.1007/s00347-014-3041-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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A 14-year-old girl with blurry vision and pancytopenia. J Pediatr 2013; 163:607-607.e1. [PMID: 23623524 DOI: 10.1016/j.jpeds.2013.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 03/11/2013] [Indexed: 11/22/2022]
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