Visual recovery after radiation therapy for bilateral subfoveal acute myelogenous leukemia (AML)

Radiation Retinopathy: Detection and Management Strategies

A gradual shift in trend from primary enucleation to globe salvaging radiation therapy for the management of ocular tumors has resulted in the rise of several post-treatment ocular complications including radiation retinopathy. Radiation retinopathy is a chronic, progressive, and occlusive vasculopathy that can manifest anytime between 1 month to 15 years after starting radiation therapy. The aim of treatment in most of these cases is to prevent further vision loss. Treatment options such as laser photocoagulation, anti-vascular endothelial growth factor and intraviral steroids have been described. However, despite several advances in diagnostic and therapeutic modalities, a significant proportion of eyes with radiation retinopathy eventually go blind. This review summarises some of the clinical features, investigative modalities, and recent therapeutic strategies used in the management of radiation retinopathy.

Ophthalmic manifestations of leukemia

PURPOSE OF REVIEW

This article aims to describe the ocular manifestations of leukemia, resulting both from direct infiltration of neoplastic cells and from the more common secondary effects of leukemia and its treatment. The prevalence of these findings is also discussed, along with their clinical significance, association with hematologic markers and the ophthalmologist's role caring for these patients.

RECENT FINDINGS

Recent studies have included a large case series examining the prevalence of ocular manifestations in newly diagnosed leukemic patients as well as case reports of ocular manifestations of leukemia.

SUMMARY

Patients with leukemia often have ocular manifestations. These occur either from direct infiltration of neoplastic cells or from indirect or secondary causes, including hematologic abnormalities, central nervous system involvement, opportunistic infections, or from treatment. Although nearly all ocular structures can be affected, leukemic retinopathy is often the most clinically apparent manifestation. Awareness of the ophthalmic manifestations of leukemia is important as they may precede systemic diagnosis or may be a sign of leukemia recurrence.

Acute Myeloid Leukemia Relapse Presenting as Complete Monocular Vision Loss due to Optic Nerve Involvement

Acute myeloid leukemia (AML) involvement of the central nervous system is relatively rare, and detection of leptomeningeal disease typically occurs only after a patient presents with neurological symptoms. The case herein describes a 48-year-old man with relapsed/refractory AML of the mixed lineage leukemia rearrangement subtype, who presents with monocular vision loss due to leukemic eye infiltration. MRI revealed right optic nerve sheath enhancement and restricted diffusion concerning for nerve ischemia and infarct from hypercellularity. Cerebrospinal fluid (CSF) analysis showed a total WBC count of 81/mcl with 96% AML blasts. The onset and progression of visual loss were in concordance with rise in peripheral blood blast count. A low threshold for diagnosis of CSF involvement should be maintained in patients with hyperleukocytosis and high-risk cytogenetics so that prompt treatment with whole brain radiation and intrathecal chemotherapy can be delivered. This case suggests that the eye, as an immunoprivileged site, may serve as a sanctuary from which leukemic cells can resurge and contribute to relapsed disease in patients with high-risk cytogenetics.