Optic nerve lymphoma: report of two cases and review of the literature

Uveitis masquerade syndromes: An approach to diagnosis

Uveitis masquerade syndromes are a diverse group of clinical entities which mimic conventional immune-mediated uveitis due to the presence of inflammatory signs but are resistant to anti-inflammatory therapy. Misdiagnosis hinders appropriate management in these conditions and may result in poor outcomes. This review discusses commonly encountered neoplastic and non-neoplastic disease processes that masquerade as intraocular inflammation with a focus on relevant clinical features and adjunctive investigations that are helpful in reaching a correct diagnosis.

Optic nerve infiltration in systemic non Hodgkin lymphoma

Optic nerve infiltration secondary to systemic non-Hodgkin lymphoma (NHL) is a rare phenomenon. We present a 55-year-old man with low-grade systemic NHL who initially presented with an isolated optic neuropathy and non-specific neurological symptoms. We further present a literature review of systemic NHL with radiological evidence of optic nerve infiltration. On magnetic resonance imaging, the characteristic features include optic nerve enhancement and enlargement, while leptomeningeal enhancement is uncommon. Cerebrospinal fluid analysis and optic nerve sheath biopsy can return false negative results, and when such investigations are inconclusive, biopsy of the optic nerve substance has a high diagnostic yield. Although rare, lymphomatous optic nerve infiltration must be considered in the differential diagnosis of a pale swollen optic disc.

Primary Central Nervous System Lymphoma Presenting as Optic Nerve Infiltration: A Case Report

Primary central nervous system lymphoma (PCNSL) is a rare type of non-Hodgkin lymphoma, which uncommonly presents with optic nerve infiltration (ONI). ONI has been reported mostly in relapse cases of PCNSL and is rarely the sole manifestation of the disease at the time of diagnosis. We report a case of a 69-year-old female who presented with progressive visual impairment with relative afferent pupillary defect (RAPD) on examination. Orbital and cranial magnetic resonance imaging (MRI) revealed bilateral optic nerve sheath contrast enhancement with an incidental finding of a right frontal lobe mass. Routine cerebrospinal fluid analysis and cytology were unremarkable. Excision biopsy of the frontal lobe mass yielded the diagnosis of a diffuse B-cell lymphoma. Intraocular lymphoma was excluded on ophthalmologic workup. Whole body positron emission tomography scan did not reveal extracranial involvement establishing the diagnosis of PCNSL. Chemotherapy was initiated with rituximab, methotrexate, procarbazine, and vincristine as induction regimen and cytarabine as consolidation therapy. On follow-up, the visual acuity of both eyes significantly improved with the resolution of RAPD. Repeat cranial MRI did not show a recurrence of the lymphomatous process. To the best of the authors' knowledge, ONI as the initial presentation at the time of PCNSL diagnosis has only been reported three times. The present case's unusual presentation highlights the need to consider PCNSL as a differential diagnosis in patients who present with visual deterioration and optic nerve involvement. Prompt evaluation and treatment of PCNSL are essential for improving the visual outcomes of patients.

Primary non-Hodgkin lymphoma of the chiasm and optic tract in a nonimmunocompromised patient: illustrative case

BACKGROUND

Chiasmatic and optic track lymphoma as the primary lesion of the central nervous system (CNS) is extremely rare.

OBSERVATIONS

The authors report a case of a previously healthy 62-year-old woman who presented with quick and progressive visual impairment leading to bilateral blindness. Brain imaging studies suggested glioma or lymphoma of the chiasm and the posterior visual pathway. Postoperative examination revealed low-grade malignant B-cell lymphoma. No evidence of extracranial lymphoma was found, so a final diagnosis of primary CNS lymphoma (PCNSL) was made.

LESSONS

To the authors' knowledge, PCNSL confined to the optic chiasm has rarely been reported in nonimmunocompromised patients. The present case of lymphoma affecting the optic chiasm and optic tract is extremely rare.

Infiltration of Bilateral Optic Nerves in Burkitt Lymphoma: A Case Report

Burkitt lymphoma (BL) is one of the highly aggressive non-Hodgkin B-cell lymphomas. The optic nerve can be affected in case of isolated lymphoma or together with the central nervous system (CNS) and systemic lymphoma. We report a rare case of involvement of bilateral optic nerves in BL. A 31-year-old lady who was diagnosed with BL presented with severe intermittent headache and vomiting with blurring of vision in both eyes for one week. Visual acuity on presentation was 6/9 in the right eye and 6/24 in the left eye, with a reduction of the left eye optic nerve functions. Fundoscopy showed swollen optic disc in the right eye and temporal pallor disc in the left. Magnetic resonance imaging of the brain and orbit showed increased leptomeningeal enhancement in the right frontal and temporal lobes and the right optic nerve. Lumbar puncture revealed high opening pressure (50 cmH₂O). Pleocytosis and the presence of lymphomatous infiltration were noted in cerebrospinal fluid analysis. After the completion of four cycles of chemotherapy, her condition unfortunately deteriorated, and she was subsequently planned for palliative therapy. CNS-directed therapies should be considered given the high risk of CNS relapse.

Neoplastic nerve lesions

Though metastasis and malignant infiltration of the peripheral nervous system is relatively rare, physicians should have a familiarity with their presentations to allow for prompt diagnosis and initiation of treatment. This article will review the clinical presentations, diagnostic evaluation, and treatment of neoplastic involvement of the cranial nerves, nerve roots, peripheral nerves, and muscle. Due to the proximity of the neural structure traversing the skull base, metastasis to this region results in distinctive syndromes, most often associated with breast, lung, and prostate cancer. Metastatic involvement of the nerve roots is uncommon, apart from leptomeningeal carcinomatosis and bony metastasis with resultant nerve root damage, and is characterized by significant pain, weakness, and numbness of an extremity. Neoplasms may metastasize or infiltrate the brachial and lumbosacral plexuses resulting in progressive and painful sensory and motor deficits. Differentiating neoplastic involvement from radiation-induced injury is of paramount importance as it dictates treatment and prognosis. Neurolymphomatosis, due to malignant lymphocytic infiltration of the cranial nerves, nerve roots, plexuses, and peripheral nerves, deserves special attention given its myriad presentations, often mimicking acquired demyelinating neuropathies.

Optic Nerve Infiltration in Systemic Lymphoma in an HIV Patient

Different mechanisms have been proposed in lymphomatous involvement of the optic nerve. They include isolated optic nerve lymphoma, optic nerve lymphoma associated with primary central nervous system (CNS) lymphoma, or with systemic lymphoma. We present one case of non-Hodgkin lymphoma of the optic nerve in a Human Immunodeficiency Virus (HIV) patient and discuss the mechanism of metastasis, classification of optic nerve involvement with clinical and radiologic features as well as treatment options. Despite the uncommon nature of optic nerve infiltration by lymphoma, prompt evaluation should be considered in patients with a history of lymphoma and visual symptoms as delays in treatment can result in permanent vision loss. The recommended initial workup includes neuroimaging and cerebrospinal fluid evaluation. Treatment options are not standardized but include intravenous and intrathecal chemotherapy, corticosteroids, and radiation.

Magnetic resonance imaging of the orbit, Part 2: Characterization of orbital pathologies

In this article we focus on a systematic approach to assess common orbital lesions on magnetic resonance imaging (MRI). The identification of the probable compartment or structure of origin helps narrow the differential diagnosis of a lesion. Analyzing the morphology, appearance, and signal intensity on various sequences, the pattern, and degree of contrast enhancement are key to characterize lesions on MRI. Imaging features suggesting cellularity and vascularity can also be determined to help plan for biopsy or surgery of these lesions. MRI can also distinguish active from chronic disease in certain pathologies and aids in selecting appropriate medical management. MRI may thus serve as a diagnostic tool and help in guiding therapeutic strategies and posttreatment follow-up.

Primary disease sites and patterns of spread in cases of neurolymphomatosis in the orbit associated with lymphoma

BACKGROUND

Neurolymphomatosis involving the cranial nerves (CNs) is rare. We sought a better understanding of the primary disease sites and patterns of spread in neurolymphomatosis of the orbit and retro-orbital cranial nerves.

METHODS

Patients with lymphoma and MRI evidence of neurolymphomatosis of CN II, III, IV, V₁, or V₂ were retrospectively reviewed. Demographics and primary disease site and sites of neurolymphomatosis on MRI were recorded. Wilcoxon rank sum test was used to compare number of sites of neurolymphomatosis with lymphoma type and survival.

RESULTS

The study included 18 patients. The most frequent types of lymphoma were diffuse large B-cell (DLBCL) (n = 9) and marginal zone (n = 3). In 9 patients, lymphoma presented as a mass (n = 7) or infiltrative disease (n = 2) directly involving the orbit; in 6, a maxillofacial mass spread directly to CNs; and in 3, lymphoma at remote sites spread to orbital CNs. Overall, 81 sites of neurolymphomatosis were noted. The most common sites were the maxillary nerve (V₂) including at the infraorbital fissure or foramen rotundum (17 patients; 19 nerves), pterygopalatine fossa (16 patients; 19 nerves), and cavernous sinus (9 patients; 12 nerves). Number of sites of neurolymphomatosis was significantly lower for DLBCL than for other lymphoma types (p = 0.007). Number of sites of neurolymphomatosis did not affect survival (p = 0.26). The mean interval between the pathologic diagnosis and MRI documentation of the full extent of neurolymphomatosis was 39 days after pathologic diagnosis.

CONCLUSIONS

Based on our study results, neurolymphomatosis in the orbit appears to be frequently associated with an orbital and/or maxillofacial mass and commonly involves CN V₂, the pterygopalatine fossa, and the cavernous sinus. DLBCL may be associated with fewer sites of neurolymphomatosis than other lymphomas. In patients with lymphoma, a systematic search for neurolymphomatosis is imperative for early detection.

Bilateral optic disc swelling resulting from lymphocytic meningitis and posterior uveitis secondary to syphilis

Idiopathic intracranial hypertension (IIH) is being diagnosed more often in the UK due to the rise in obesity. In fact, patients who present with bilateral optic disc swelling are habitually put on the papilloedema pathway, often without consideration of other diagnoses. We report the case of a middle-aged woman diagnosed with papilloedema and managed as IIH, until, cerebrospinal fluid (CSF) analysis revealed evidence of lymphocytic meningitis secondary to syphilis. The patient was treated successfully with intravenous antibiotics. Syphilis is the great masquerader and should be a diagnosis to consider in patients who have CSF findings incongruent with their clinical presentation.

Perineuritis or infiltration of optic nerve sheath? A presentation of diffuse large B cell Gastric lymphoma

Optic perineuritis is an inflammatory disorder involving the optic nerve sheath. It is currently considered as a part of idiopathic orbital inflammatory disease which also includes dacryoadenitis, orbital myositis, superior orbital fissure, and cavernous sinus syndrome (Tolosa hunt syndrome). As it is idiopathic, it is considered a diagnosis of exclusion. Another important differential is optic nerve lymphoma. Isolated optic nerve lymphoma associated with systemic involvement has been described in literature. We report a case that presented as third nerve palsy but later on developed central retinal vein occlusion and was ultimately diagnosed as primary gastric lymphoma of diffuse large B cell type.

Bilateral Simultaneous Lymphomatous Optic Nerve Infiltration in Sporadic Burkitt's Lymphoma

Burkitt's lymphoma is a highly aggressive mature B cell non-Hodgkin's lymphoma. Systemic non-Hodgkin's lymphoma with isolated metastasis to the optic nerve was found only in one case among nearly six thousand cases of all types of non-Hodgkin's lymphoma. However, bilateral simultaneous lymphomatous optic nerve infiltration without central nervous system (CNS) involvement has not been reported previously. Herein, we present a unique case of simultaneous bilateral optic nerve infiltration without concomitant CNS involvement in sporadic Burkitt's lymphoma.

Optic nerve biopsy in leukemic infiltrative optic neuropathy: a case report and review of the literature

Optic nerve infiltration is a rare but known complication of the central nervous system (CNS)-involving lymphoma and leukemic disorders. The diagnosis is often presumed and patients are empirically treated with systemic therapy and/or local radiation. Optic nerve biopsy is usually avoided due to the risk of permanent vision loss secondary to the procedure. We present a case of biopsy-proven leukemic optic neuropathy without optic nerve sheath or cerebrospinal fluid (CSF) involvement in a patient previously in remission from T-cell prolymphocytic leukemia (T-PLL). To our knowledge, this is the first documented case of T-PLL with biopsy-proven optic nerve invasion without CSF involvement and suggests possible perineural invasion or a sanctuary site from chemotherapy. We suggest that for patients with poor vision and suspected leukemic infiltration without other evidence of CNS involvement, both optic nerve and optic sheath biopsy should be performed for diagnosis and treatment.

Vitreoretinal Lymphoma: A Literature Review and Introduction of a New Diagnostic Method

PURPOSE

The aim of this study was to briefly review the clinical and diagnostic features of vitreoretinal lymphoma (VRL) and to introduce the recent introduction of metagenomic deep sequencing in this ocular lymphomatous disease.

DESIGN AND METHODS

Review and description of the process of using metagenomic deep sequencing for ocular specimens at the Proctor Foundation, University of California, San Francisco, CA.

RESULTS

VRL masquerades as a uveitis, but clinical signs of subretinal lesions, and vitritis should prompt the inclusion of VRL in a differential diagnosis. Imaging features such as hyporeflective infiltrative lesions between the retinal pigment epithelium and Bruch's membrane are compatible with VRL, but diagnosis requires satisfying specific cytopathological and immunohistochemical or molecular features. Diagnosis, then, is subject to the cellularity, viability, and volume of the specimen submitted for these tests. Metagenomic deep sequencing has the ability to detect numerous lymphoma-associated mutations and is able to utilize minute volume samples and cell-free nucleic acid, so is well-suited for ocular tissues.

CONCLUSIONS

Metagenomic deep sequencing may offer an additional tool in the future with which to diagnose VRL.

Optic Nerve Infiltration in Systemic Metastatic Retinal Lymphoma (SMRL): Multimodal Imaging and Challenges in Diagnosis

A 45-year-old man was diagnosed with diffuse large B-cell lymphoma stage IV which was confirmed by celiac lymph node biopsy. He subsequently completed six cycles of R-CHOP chemotherapy. Six months later, he presented with panuveitis OU with positive relative afferent pupillary defect OD. OCT revealed hyper-reflective lesions and irregularity of the retinal pigment epithelium OU. Fundus fluorescein angiogram shows hyper-auto fluorescence and granular changes on the retina. A month later, he developed swollen optic disc OD and hemorrhagic retinitis OU and treated as presumed CMV retinitis. Anti-TB was started after a positive Mantoux test. He finally consented for a vitreous biopsy which showed atypical lymphoid cells highly suggestive for vitreoretinal lymphoma and subsequently received intravitreal methotrexate OU.Conclusion: Optic nerve infiltration in systemic metastatic retinal lymphoma may have initial occult signs but with profound visual loss. Ocular infections like CMV retinitis and tuberculosis may mask and delay the diagnosis in immunocompromised patients.

Swept Source Optical Coherence Tomography Documenting Optic Nerve Involvement in an Aggressive T-Cell Lymphoma

Peripheral T-cell lymphomas (PTCLs) are a heterogeneous group of aggressive neoplasms. The involvement of ocular structures in haematological neoplasms is rare and usually associated with central nervous system involvement, which may occur as a result of orbital invasion and optic nerve infiltration. In this case report, we describe ocular findings using the novel swept source optical coherence tomography (SS-OCT) in a case of aggressive T-cell lymphoma. SS-OCT has faster scanning speed, deeper tissue penetration due to its longer wavelength laser of 1050 nm and wider scanning areas. In the present case, SS-OCT was helpful in documenting increased retinal nerve fibre layer thickness and prelaminar protrusion associated with visual loss in a patient with an aggressive T-cell lymphoma.

Orbital Magnetic Resonance Imaging May Contribute to the Diagnosis of Optic Nerve Lymphoma

Background: Optic nerve lymphoma can present a diagnostic challenge because of its confusing clinical features and the difficulty of obtaining lesion tissue for biopsy. The objective of this study was to find some flags of lymphomatous infiltration of optic nerves. Methods: We report two cases of optic nerve lymphoma and conduct a literature review to determine whether a common diagnostic characteristic can be identified. Results: We examined 22 optic nerve lymphoma cases. Thirteen cases were systemic lymphoma infiltration of the optic nerve, five were primary central nervous system lymphoma (PCNSL), and four were primary isolated optic nerve lymphoma. Twenty patients manifested significant enlargement of the lesions in orbital/brain MRI. Seventeen contrast-enhanced MRIs showed abnormal enhancement of the optic nerve. All PCNSL and isolated optic nerve lymphoma patients in the series showed marked enhancement. Moderate and subtle enhancement was found in systemic lymphoma patients only. At the enhancement site, six isolated optic nerve lymphoma and PCNSL patients presented intrinsic enhancement, ten systemic patients showed both optic nerve and sheath enhancement, and one demonstrated sheath enhancement. Cerebrospinal fluid (CSF) tests showed elevated protein levels in six patients, and a neoplasm in one patient. We found abnormality of CSF immunity in both of our patients. Conclusion: Combined characteristics of orbital MRI and CSF tests may facilitate expeditious suspicion establishment of optic nerve lymphoma.

Stage IV Small Lymphocytic Lymphoma Presenting with Unilateral Vision Loss

Small lymphocytic lymphoma (SLL) is a manifestation of chronic lymphocytic leukemia (CLL) in which malignant B-cell lymphocytes accumulate in the lymph nodes or bone marrow. In this report, we describe the medical course of a patient diagnosed with stage IV small cell lymphocytic lymphoma, who presented to the emergency room with acute neurologic manifestations of SLL.

B-scan ultrasound and cytology of the vitreous in primary central nervous system lymphoma with vitreoretinal involvement

AIM

To evaluate the diagnostic value of B-scan ultrasound and explore the cytological characteristics of patients with vitreoretinal lymphoma (VRL) and primary central nervous system lymphoma (PCNSL).

METHODS

The clinical data and pathologic specimens from patients with VRL diagnosed at the North Huashan Hospital from 2016 to 2017 were retrospectively reviewed. The patients were diagnosed by slit lamp ophthalmoscopy, B-scan ultrasound, cytology of the vitreous, which was obtained by vitrectomy, and cytokine measurements of interleukin (IL)-10 and IL-6.

RESULTS

Twenty-six eyes (19.4%) out of 134 eyes of 67 patients (47 men and 20 women) with PCNSL were diagnosed with VRL by B-scan ultrasound, and 14 eyes (10.4%) were diagnosed by slit lamp ophthalmoscopy. Twenty-four eyes (17.9%) of 17 patients were confirmed as having VRL with cytology. No difference in the association between intracranial lesion location and ocular involvement was found. VRL patients had higher levels of vitreous IL-10 and IL-10/IL-6 when compared with macular hole cases, but the difference was not statistically significant.

CONCLUSION

A total of 25.4% of the PCNSL patients had VRL, B-scan ultrasound examination had characteristic features and is recommended over slit lamp ophthalmoscopy for the screening diagnosis of PCNSL with intraocular involvement. Moreover, the cytological and immunohistochemical analyses performed after 25-gauge diagnostic vitrectomy were accurate diagnostic techniques.

A Case of Compressive Optic Neuropathy Secondary to Lymphoma of the Extraocular Muscles

Compressive optic neuropathy is an urgent condition that may lead to blindness. We report a rare case of compressive optic neuropathy secondary to lymphoma of the extraocular muscles in which the vision was successfully rescued. A 67-year-old man presented with visual acuity of hand motion in the right eye for 1 month. Magnetic resonance imaging demonstrated enlargement of the medial and inferior rectus muscles with their tendons. Tendon enlargement, which is uncommon as Graves' orbitopathy, motivated us to perform a biopsy. Intravenous steroids following biopsy and chemotherapy after definitive diagnosis allowed for recovery of vision. Clinicians should be aware that enlarged extraocular muscles due to lymphoma can cause compressive optic neuropathy.

Peripheral nervous system involvement in lymphomas

The peripheral nervous system may be involved at any stage in the course of lymphoproliferative diseases. The different underlying mechanisms include neurotoxicity secondary to chemotherapy, direct nerve infiltration (neurolymphomatosis), infections, immune-mediated, paraneoplastic or metabolic processes and nutritional deficiencies. Accordingly, the clinical features are heterogeneous and depend on the localization of the damage (ganglia, roots, plexi, and peripheral nerves) and on the involved structures (myelin, axon, and cell body). Some clinical findings, such a focal or diffuse involvement, symmetric or asymmetric pattern, presence of pain may point to the correct diagnosis. Besides a thorough medical history and neurological examination, neurophysiological studies, cerebrospinal fluid analysis, nerve biopsy (in selected patients with suspected lymphomatous infiltration) and neuroimaging techniques (magnetic resonance neurography and nerve ultrasound) may be crucial for a proper diagnostic workup.

Posterior Tibial Nerve Lymphoma Presenting as Tarsal Tunnel Syndrome: A Case Report

We report a case of isolated posterior tibial B-cell lymphoma of the posterior tibial nerve presenting as tarsal tunnel syndrome. This diagnosis was considered because of the clinical presentation and electrophysiologic abnormalities. It was further confirmed by the magnetic resonance imaging findings of the ankle and tissue pathologic findings. Whole body positron emission tomography confirmed this to be a localized lymphoma involving the peripheral nerve. The patient underwent chemotherapy with complete tumor resolution. She had had no relapse after 8 months of follow-up. Isolated peripheral nerve lymphomas are very rare, and involvement of the posterior tibial nerve has not been previously reported. Furthermore, the present case report highlights the importance of the clinical examination in the diagnosis of tarsal tunnel syndrome before performing surgical decompression.

Macular ganglion cell complex measurement in bilateral retrobulbar optic neuropathy without a relative afferent pupillary defect

Purpose

This study aimed to demonstrate the clinical usefulness of measuring the macular ganglion cell complex (GCC) for the early detection of axonal loss in eyes with bilateral retrobulbar optic neuropathies.

Patients and methods

We retrospectively reviewed the medical records of three patients with bilateral toxic, ischemic, or infiltrative retrobulbar optic neuropathy.

Results

No relative afferent pupillary defect was detected in any patients. The results of the fundus examinations were unremarkable at the initial presentation except for slight optic disk pallor in the right eye of Case 3. Magnetic resonance imaging showed no abnormal findings in Cases 1 and 2. Measurement of the macular GCC clarified the presence of axonal loss in all three cases with diagnostic uncertainty. Although reduction in the macular GCC thickness was not observed initially in Case 2, it became evident later when both optic disks still appeared normal.

Conclusion

A reduction in the macular GCC thickness seemed to precede the appearance of optic disk pallor and occurs regardless of toxic, ischemic, or infiltrative retrobulbar optic neuropathy. The current case series suggested that measurement of the macular GCC facilitated early differentiation between bilateral retrobulbar optic neuropathy and nonorganic visual loss, which can otherwise be challenging in some cases.

Ethics of a therapeutic trial: addressing limitations of an active intervention in optic nerve lymphoma

We report a unique case of optic nerve lymphoma after completion of chemotherapy for non-Hodgkin's lymphoma. The uncommon nature of presentation, our therapeutic dilemma and the further course of treatment are reported. In cases with extremely poor prognosis, unnecessary treatment puts additional strain both financially and psychologically on the patients and their family. Therapeutic focus should be on hospice care and family counselling. The decision to not treat is a crucial component of cancer management; however, the ethics of this decision are yet to be suitably addressed by the literature.

Plexus and peripheral nerve metastasis

Cancer in the form of solid tumors, leukemia, and lymphoma can infiltrate and metastasize to the peripheral nervous system, including the cranial nerves, nerve roots, cervical, brachial and lumbosacral plexuses, and, rarely, the peripheral nerves. This review discusses the presentation, diagnostic evaluation, and treatment options for metastatic lesions to these components of the peripheral nervous system and is organized based on the anatomic distribution. As skull base metastases (also discussed in Chapter 14) result in cranial neuropathies, these will be covered in detail, as well as cancers that directly infiltrate the cranial nerves. Particular emphasis is placed on the clinical, imaging, and electrodiagnostic features that differentiate neoplastic plexopathies from radiation-induced plexopathies. Neurolymphomatosis, in which malignant lymphocytes invade the cranial nerves, nerve roots, brachial and lumbosacral plexuses, and peripheral nerves, is a rare manifestation of lymphoma and leukemia. Diagnoses of neurolymphomatosis are often missed or delayed given its varied presentations, resulting in poorer outcomes. Thus this disease will also be discussed in depth.

Optic Nerve Infiltration in Primary Central Nervous System Lymphoma

Importance

Visual impairment in primary central nervous system lymphoma (PCNSL) is caused mostly by intraocular lymphomatous involvement (vitritis and retinal infiltration), whereas optic nerve infiltration (ONI) is a rare condition.

Objective

To describe the clinical presentation of ONI, its imaging characteristics, and outcome.

Design, Setting and Participants

A total of 752 patients diagnosed with PCNSL were retrospectively identified from the databases of 3 French hospitals from January 1, 1998, through December 31, 2014. Of these, 7 patients had documented ONI. Exclusion criteria were intraocular involvement, orbital lymphoma, or other systemic lymphoma. Clinical presentation, neuroimaging, biological features, treatment, and outcomes were assessed.

Main Outcomes and Measures

Treatment response was evaluated clinically and radiologically on follow-up magnetic resonance imaging (MRI) according to the International PCNSL Collaborative Group response criteria.

Results

The 7 patients included 5 women and 2 men. Median age at diagnosis was 65 years (range, 49-78 years). Two patients had initial ONI at diagnosis, and 5 had ONI at relapse. Clinical presentation was marked by rapidly progressive and severe visual impairment for all patients. The MRI findings showed optic nerve enlargement in 3 patients and contrast enhancement of the optic nerve in all patients. Additional CNS lesions were seen in 4 patients. Examination of cerebrospinal fluid samples detected lymphomatous meningitis in 2 patients. Clinical outcome was poor and marked by partial recovery for 2 patients and persistent severe low visual acuity or blindness for 5 patients. Median progression-free survival after optic nerve infiltration was 11 months (95% CI, 9-13 months), and median overall survival was 18 months (95% CI, 9-27 months).

Conclusions and Relevance

Optic nerve infiltration is an atypical and challenging presentation of PCNSL. Its visual and systemic prognosis is particularly poor compared with vitreoretinal lymphomas even in response to chemotherapy. Although intraocular involvement is frequent in PCNSL and clinically marked by slowly progressive visual deterioration, lymphomatous ONI is rare and characterized by rapidly progressive severe visual impairment.

Case of Primary Leptomeningeal Lymphoma Presenting with Papilloedema and Characteristics of Pseudotumor Syndrome

The authors describe an immunocompetent, 50-year-old man who complained of a daily transient blurring of his vision with bilateral papilloedema. His visual acuity was 20/20 OU, and the blind spot was enlarged bilaterally. There was intracranial hypertension, but imaging for systemic and brain tumours were negative. These findings suggested a diagnosis of the pseudotumor syndrome. However, MRI showed leptomeningeal enhancement, and acetazolamide successfully resolved his visual symptoms and papilloedema. Cytology and flow cytometry of the CSF led to the final diagnosis of primary leptomeningeal lymphoma (PLML). Clinicians need to be aware that a case of PLML may be misdiagnosed as peudotumor cerebri.

Ocular Adnexal Lymphoma Presenting with Visual Loss

Context:

Elderly patients with visual loss often have age-related macular degeneration, diabetic retinopathy, glaucoma, and cataract as common causes of visual loss. Other less common etiologies should be considered, especially in those presenting with systemic associations.

Case Report:

The patient discussed in our review is an 80-year-old female, with a history of diabetic retinopathy and macular degeneration who presented with a sudden deterioration of vision. While this was initially attributed to diabetic retinopathy, she was eventually noted to have a salmon patch lesion in her conjunctiva, diagnosed on biopsy to be a diffuse large B-cell lymphoma.

Conclusion:

Because of the significant rate of disseminated disease among patients with lymphomas in the orbit that carries a worse prognosis, early diagnosis is essential to promote better overall survival of these patients. We describe here a patient diagnosed with conjunctival lymphoma associated with pronounced visual loss and review the literature on this subject.