Isolated Ocular Manifestation of Relapsed Chronic Myelogenous Leukemia Presenting as Myeloid Blast Crisis in a Patient on Imatinib Therapy: A Case Report and Review of the Literature

Assessment of retinal, choroidal and peripapillary microvascular changes in patients with chronic myeloid leukemia

PURPOSE

To quantitatively assess the microvascular alterations and structural parameters in the optic disc, retina, and choriocapillaris of chronic myeloid leukemia (CML) patients devoid of leukemic retinopathy, while also examining the correlation between these parameters and serum laboratory results.

STUDY DESIGN

Prospective, cross-sectional, observational clinical study METHODS: This study included 30 eyes from 15 patients diagnosed with CML and 30 eyes from age 15- and gender-matched healthy individuals (control group). All participants underwent comprehensive ophthalmologic assessments, including optical coherence tomography angiography (OCTA). Statistical analyses, including Student's t-test and the Mann-Whitney U test, were conducted to compare structural and vascular parameters between CML patients and controls. Spearman's correlation was used to evaluate the relationship between OCTA measurements and serum parameters.

RESULTS

The analysis of macular vessel density revealed significant reductions in all assessed parameters in the patient group compared to the control group. These parameters include whole image superficial vessel density (wisVD, p=0.005), parafoveal superficial vessel density (pfsVD, p=0.002), perifoveal superficial vessel density (pefsVD, p=0.007), whole image deep vessel density (widVD, p=0.005), parafoveal deep vessel density (pfdVD, p=0.004), and perifoveal deep vessel density (pefdVD, p=0.005). Higher white blood cell levels were associated with lower optic nerve head whole image VD, wisVD, pfsVD, pefsVD, widVD, and pefdVD. Higher platelet levels were correlated with lower widVD. Additionally, hemoglobin showed a positive correlation with choriocapillaris vessel flow density, while it exhibited a negative correlation with superior and inferior macular ganglion cell complex thickness.

CONCLUSION

Subclinical retinal perfusion loss was observed in CML patients, and this perfusion loss was associated with hematological parameters. The marked reduction in macular perfusion could be valuable for understanding the pathogenesis of the disease and predicting potential retinal complications such as hypoxia and ischemia in more advanced stages. Further studies are needed to investigate the functional and prognostic significance of the changes we observed.

Non-Blast Phase Chronic Myelogenous Leukemia Presenting as Bilateral Infiltration of the Optic Nerve

A 27-year-old woman presented with bilateral blurry vision for 2 weeks. She had a presumed diagnosis of idiopathic intracranial hypertension given her bilateral disc edema; however, bilateral disc and retinal infiltration was noted on ophthalmoscopy. This report presents a rare case of chronic myelogenous leukemia (CML) in the non-blast phase presenting as bilateral optic disc infiltration, indicating central nervous system involvement at the time of diagnosis. The patient had no other clinical symptoms at the time of diagnosis and was promptly treated with orbital radiation and a tyrosine kinase inhibitor, resulting in 20/20 vision in both eyes. [Ophthalmic Surg Lasers Imaging Retina 2025;56:102-107.].

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.

Isolated Ocular Manifestations in Chronic Myeloid Leukaemia

BACKGROUND

Chronic myeloid leukaemia (CML) presenting with only ocular manifestations either at the initial stage of diagnosis or at relapse is uncommon. We report two cases of CML presenting with isolated visual symptoms.

CASE SERIES

The first case is a 21-year-old healthy gentleman who presented with left eye painless loss of vision for a one-week duration. Visual acuity was 6/60 in the left eye and 6/6 in the right eye. There were scattered retinal haemorrhages in both eyes and a sub-macular bleed over the left eye. The full blood count revealed a high white cell count of 134.6 × 10⁹/L. Peripheral blood smear showed hyper-leucocytosis with absolute eosinophilia and basophilia and the presence of blasts suggestive of CML thus chemotherapy was commenced. The second case is a 28-year-old in haematological, molecular, and cytogenic remission from CML for the past two years, presented with left eye painless vision loss for five days duration. Vision in the left eye was counting fingers. There was a large subretinal mass involving the left optic disc. Magnetic resonance imaging of the brain and orbit showed an elliptical orbital mass at the left globe posteriorly with diffuse thickening of the optic nerve. The patient was diagnosed as CML relapsed to the left optic nerve. He underwent intrathecal chemotherapy and orbital irradiation.

CONCLUSION

Both these cases are unique since the manifestation of CML was with only ocular features at the time of presentation as per in the first case during the initial diagnosis and in the second case during relapse. This highlights that it is evident that the knowledge of ocular involvement in leukaemia is crucial since the eye is the only organ where leukemic infiltration to nerves and blood vessels can be observed directly. Recognizing fundus changes in leukaemia allows earlier diagnosis and prompt treatment. These case reports highlight the importance of recognizing early fundus changes, which should allow earlier diagnosis and treatment.

Bilateral Serous Retinal Detachment in Lymphoid Blast Crisis of Chronic Myeloid Leukemia

We herein report a patient with Philadelphia chromosome-positive lymphoid blast crisis of chronic myeloid leukemia (CML), who presented with bilateral serous retinal detachment (SRD). A 36-year-old Asian male presented with the symptoms of decreased vision and was found to have bilateral SRD involving fovea. There was no inflammation in the anterior chamber or vitreous. Physical examination showed hepatomegaly and splenomegaly. A blood count revealed white blood cell count of 38.2 × 10⁹/L with 51.5% blast cells. Bone marrow aspirate showed total cell count of 145 × 10³/μL with 80.6% blast cells and negative neutrophil myeloperoxidase staining. Cytogenetic analysis using fluorescence in situ hybridization confirmed a 9;22 chromosomal translocation, indicating the presence of the Philadelphia chromosome. Flow cytometry analysis demonstrated expression of CD10, CD19, and positive TdT. According to morphology, immunology, cytogenetics, and molecular criteria, the patient was diagnosed as having Philadelphia chromosome-positive lymphoid blast crisis of CML. Based on the ocular findings and hematological abnormalities, the SRD was considered to be ocular involvement secondary to the blast crisis of leukemia. Two months after starting induction therapy, fundus examination and optical coherence tomography showed complete resolution of bilateral SRD and improved vision. Prompt diagnosis of the disease leads to early systemic chemotherapy and may help restore visual function and improve survival.

Intraocular infiltration of Philadelphia chromosome-positive acute lymphoblastic leukemia diagnosed by polymerase chain reaction from the aqueous humor: A case report

RATIONALE

Intraocular manifestation of hematopoietic tumors is rare and often difficult to distinguish from inflammation. We report a patient with acute lymphoblastic leukemia (ALL) who developed intraocular infiltration during the remission period.

PATIENT CONCERNS

A 40-year-old man presented with hypopyon in his right eye. Three months later, extensive subretinal infiltration and the elevation of intraocular pressure were observed. Fourteen months prior to this, he had been diagnosed with Philadelphia chromosome-positive ALL, and had received chemotherapy and bone marrow transplantation that resulted in complete remission.

DIAGNOSIS

The breakpoint cluster region-Ableson (BCR/ABL) chimera was detected by polymerase chain reaction (PCR) analysis in the patient's aqueous humor. Additionally, a high expression of WT1 (Wilms tumor gene) mRNA in the aqueous humor was discovered. A bone marrow examination yielded a high expression of BCR/ABL fusion gene, and it was determined the patient had experienced a relapse of ALL.

INTERVENTIONS

The dasatinib was administered orally to the patient.

OUTCOMES

The intraocular infiltration disappeared, and intraocular pressure was normalized.

LESSONS

Intraocular infiltration in leukemia patients may be an indication of relapse regardless of systemic conditions. Analyzing mRNA expression of BCR/ABL and WT1 of ocular fluid in patients with hypopyon is beneficial in diagnosing topical relapses in leukemia.

A Rare Monocytic Crisis of Chronic Myelogenous Leukemia Presenting with Unusual Extramedullary Manifestations and an Atypical (14;22)(q24;q11.2) Translocation in the Bone Marrow

A 48-year-old man was admitted due to marked leukocytosis. Bone marrow examinations resulted in a diagnosis of Philadelphia (Ph) chromosome-positive chronic myeloid leukemia. One month later, massive muscle and bone invasion by leukemic cells was detected. After induction chemotherapy, he complained of a headache and visual loss, which was caused by a leukemic infiltration in the central nervous system. After temporary remission in response to chemotherapy, the disease relapsed in the form of an intracranial tumor. The unusual t(14;22)(q24;q11.2) translocation of the Ph-chromosome and the significant increase in monocytes observed might have contributed to the unique and aggressive clinical course.