Ocular Manifestations of Leukemia and Results of Treatment with Intravitreal Methotrexate

Bilateral optic nerve infiltration and leukemic retinopathy as initial signs of leukemia relapse with central nervous system involvement in an adult: a case report

BACKGROUND

We describe a case in which bilateral optic nerve infiltration and leukemic retinopathy were the initial signs of disease relapse in a patient with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+-ALL) with central nervous system (CNS) involvement.

CASE PRESENTATION

A 65-year-old Asian female with Ph+-ALL in complete remission presented at our institution with symptoms of visual disturbance, central scotoma and pain with eye movement in both eyes for a 1-month duration. Ophthalmic examination revealed remarkable optic disc swelling with multiple flame-shaped peripapillary hemorrhages, retinal venous dilation and retinal hemorrhages in both eyes. She was subsequently referred to the treating oncologist and diagnosed with Ph+-ALL relapse with multiple relapsed diseases involving the bone marrow and CNS. After intrathecal (IT) therapy, her visual acuity dramatically improved, and her leukemic infiltrates decreased.

CONCLUSIONS

To the best of our knowledge, this is the first case report of ALL relapse with CNS involvement presenting as bilateral optic nerve infiltration and leukemic retinopathy in an adult. Hence, we highlight the priority and sensitivity of ophthalmic examinations, as they are noninvasive methods for detecting leukemia relapse.

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.

Ophthalmic Manifestations in Patients with Blood Malignancies

Ocular complications can occur in up to 90% of patients with blood malignancies. Such complications range from direct infiltration to local hemostatic imbalance and treatment-related toxicity. This narrative review is based on a systematic computerized search of the literature conducted until January 2024 and examines the common ocular complications associated with blood cancers. Ocular complications from primary disease include mass effects from ocular adnexal lymphomas and intraocular lymphomas, with B-cell lymphomas accounting for 95% of primary ocular presentations. Secondary disease involvement from systemic hematological malignancies can lead to a wide range of ocular manifestations, such as leukemic retinopathy. Furthermore, toxicity from antineoplastic therapies and ocular graft versus host disease (oGVHD) after hematopoietic stem cell transplantation present additional risks to ocular health. In conclusion, ocular complications in blood cancer patients are an integral part of patient management, requiring regular ophthalmic evaluations and close collaboration between oncologists and ophthalmologists. Advances in therapy and an increased focus on early symptom recognition are essential for preserving vision and enhancing patient quality of life.

Pediatric Orbital and Skull Base Pathology

Pediatric orbital and skull base pathologies encompass a spectrum of inflammatory, sporadic, syndromic, and neoplastic processes that require a broad and complex clinical approach for both medical and surgical treatment. Given their complexity and often multicompartment involvement, a multidisciplinary approach for diagnosis, patient and family counseling, and ultimately treatment provides the best patient satisfaction and clinical outcomes. Advances in minimally invasive surgical approaches, including endoscopic endonasal and transorbital approaches allows for more targeted surgical approaches through smaller corridors beyond more classic transcranial or transracial approaches.

[Terson syndrome and acute myeloid leukemia (case report)]

The article presents a clinical case of bilateral Terson syndrome caused by the manifestation of acute myeloid leukemia. A 32-year-old man complained of a sharp decrease in vision in both eyes. Spontaneous subarachnoid hemorrhage occurred secondary to acute myeloid leukemia. Uncorrected visual acuity (UCVA) amounted to OD=0.01, OS=0.005. The anterior segment was normal in both eyes, voluminous immobile white-gray mass measuring 7-9 DD that completely covered the macula (intense hyperechoic cell suspension with a volume of about 1/2 of the vitreous cavity, ultrasound B-scan) were visualized in the posterior pole of the vitreous body of both eyes under conditions of maximum drug-induced mydriasis. Diagnosis: vitreous hemorrhage due to subarachnoid hemorrhage in both eyes secondary to acute myeloid leukemia. Vitrectomy was performed in both eyes. UCVA increased to 0.05 in both eyes. Vitrectomy contributed to improvement of visual functions and patient quality of life.

Neuro-ophthalmic Complications in Pediatric Leukemia

BACKGROUND

Optic neuropathy in childhood leukemia occurs through multiple direct and indirect mechanisms, including leukemic infiltration of the optic nerve, infection, blood dyscrasias, or adverse effects of treatment. We aimed to characterize visual outcomes in pediatric patients with leukemia-associated neuro-ophthalmic manifestations.

METHODS

We retrospectively identified patients with leukemia and optic nerve pathology over 13 years by diagnostic billing codes. We collected information on demographics, presentation, treatment course, and visual outcomes directly from medical records.

RESULTS

Of the 19 patients who met inclusion criteria, 17 (89.5%) had pseudotumor cerebri and 2 had direct optic nerve infiltration. Causes of increased intracranial pressure included central nervous system infiltration (6 of 17), hyperviscosity/leukemia (2 of 17), venous sinus thrombosis (3 of 17), medication induced (5 of 17), and bacterial meningitis (1 of 17). 47.1% (8 of 17) had papilledema at the time of leukemia diagnosis, and 94.1% (16 of 17) of patients with pseudotumor cerebri were treated with acetazolamide. At presentation, 3 patients had decreased vision secondary to macular ischemia, subhyaloid vitreous hemorrhage, or steroid induced glaucoma. Following treatment of pseudotumor cerebri, binocular visual acuity was ≥20/25 in all patients. One patient with optic nerve infiltration had a final visual acuity of count fingers in the affected eye.

CONCLUSIONS

In our chart review, the most common mechanism of neuro-ophthalmic involvement in pediatric leukemia was elevated intracranial pressure from a myriad of causes. Visual outcomes from patients with elevated intracranial pressure were excellent. Understanding the mechanisms by which leukemia can cause optic nerve disease in pediatric patients can facilitate earlier diagnosis and treatment and potentially improve visual outcomes.

Leukemic Retinopathy: A Diagnostic Clue for Initial Detection and Prognosis of Leukemia

Leukemia is a systemic malignancy that can compromise various physiological functions, including vision. We report a case of a 37-year-old male presenting with worsening bilateral central vision loss, fatigue, shortness of breath, and ankle edema. Ophthalmic examination revealed extensive retinal hemorrhages, Roth spots, and subhyaloid hemorrhages, consistent with leukemic retinopathy. Further hematologic workup confirmed chronic eosinophilic leukemia. The patient showed systemic and visual improvement after prompt treatment with imatinib. This case highlights the importance of ophthalmological assessment in diagnosing leukemia, as ocular manifestations may often be the first sign of hematological disease.

Intravitreal methotrexate in type B lymphoblastic leukemia-Case Report

Leukemia is a common neoplasia that, in its progress, can have ocular involvement due to direct infiltration or secondary to hematological alterations typical of the disease. These findings are consistent with an involvement of the central nervous system and are thus related to the prognosis. Despite the existing systemic therapies, there needs to be more literature that shows the treatment in the ocular involvement of this disease. A case report of a child with ocular involvement due to treatment-refractory acute lymphoblastic leukemia, successfully managed with intravitreal methotrexate, is presented.

A rare presentation of bilateral ophthalmic relapse of pediatric chronic myeloid leukemia: Multimodal imaging and treatment

Chronic myeloid leukemia (CML) rarely presents under 15 years of age, and its incidence is as low as 2% of all leukemia. Ophthalmic manifestations often present either initially with the diagnosis or as a sign of relapse after remission. The recommended treatment is systemic chemotherapy, intrathecal chemotherapy, ocular irradiation, and/or intravitreal methotrexate. Herein, we report a 13-year-old child with a history of CML and central nervous system relapse under remission currently. He presented to us with bilateral ophthalmic relapse. He was treated with ocular irradiation and intrathecal chemotherapy. On follow-up, the ophthalmic infiltration showed resolution, which was also seen on multimodal imaging.

Case report: Intravitreal methotrexate in intraocular acute lymphoblastic leukemia

Direct leukemic infiltration of the eye is most frequently associated with acute lymphoblastic leukemia (ALL), probably due to its well-known central nervous system (CNS) tropism. Systemic treatment alone may not be sufficient for intraocular leukemia. Data on local treatment are scarce. Here, we present two cases of intraocular ALL treated with intravitreal methotrexate (MTX). Initially, anatomical improvement and visual stability were observed. The first patient experienced anatomical and visual worsening after a year of treatment. Treatment was withheld after 2 months for the second patient due to poor systemic conditions. Corneal toxicity and intraocular pressure elevation were observed in the first case. In both cases, eye involvement was associated with CNS or systemic relapse. This highlights the importance of incorporating ocular disease management in a comprehensive approach to therapy. Our experience corroborates previous findings on MTX injections as an effective and safe therapeutic option for intraocular leukemia. Further evidence is needed to consolidate the use of intravitreal MTX to treat such a debilitating localization of leukemia.

Ocular Manifestations in Hematological Disorders

Background

Ophthalmic manifestations are a common feature in hematological malignancies and may be divided into two groups: those attributable to the disease's infiltration of the eye, and the ocular consequences due to blood abnormalities. This study aims to determine the prevalence of ocular manifestations and their association with the different hematological disease subgroups.

Materials and methods

We conducted a retrospective and observational study enrolling 137 consecutive patients on active treatment or follow-up for hematological malignancies from January 2016 to January 2020 at the Cheikh Khalifa International University Hospital. All patients underwent a standardized and comprehensive ophthalmic evaluation.

Results

Ocular involvement was primarily disclosed in acute myeloid leukemia (AML), non-Hodgkin's lymphoma (NHL), and multiple myeloma (MM). We herein report the different ocular changes divided into anterior segment manifestations, posterior segment manifestations, dry eye disease, and ocular adnexa findings. Patients with leukemia had a significantly higher rate of lesions in the ocular posterior segment (p < 0.001). Despite the high prevalence of anterior segment and ocular adnexa findings in lymphoma patients, no significant association emerged between these lesions and the aforementioned condition. In addition, dry eye disease was found in all instances without any association with the disease itself.

Conclusions

Awareness of ocular pathology in hematological malignancies is important as it may precede systemic diagnosis or be a sign of recurrence. We should also be concerned about the side effects of treatments, predominantly, dry eye disease. Therefore, periodic ophthalmic assessment throughout the disease's course, as well as interdisciplinary coordination of care, is crucial to promote early diagnosis and treatment, hence improving long-term outcomes.

A comprehensive review of intravitreal immunosuppressants and biologicals used in ophthalmology

Systemic immunosuppressants and biologicals have been a valuable tool in the treatment of inflammatory diseases and malignancies. The safety profile of these drugs has been debatable, especially in localized systems, such as the eye. This has led to the search for fairly local approaches, such as intravitreal, subconjunctival, and topical route of administration. Immunosuppressants have been used as a second-line drug in patients intolerable to corticosteroids or those who develop multiple recurrences on weaning corticosteroids. Similarly, biologicals have also been used as the next line of therapy, when adequate control of inflammation could not be attained or immunosuppressants were contraindicated to patients. Intravitreal immunosuppressants, such as methotrexate and sirolimus, have been extensively studied in noninfectious posterior uveitis, whereas limited studies have established the efficacy of intravitreal biologicals, such as infliximab and adalimumab. Most of these drugs have shown good safety profile and tolerability in animal studies alone and have not been studied further in human subjects. However, most of the studies in literature are single-case reports or case series which limits the level of evidence. In this comprehensive review, we discuss the mechanism of action, pharmacodynamics, pharmacokinetics, indications, efficacy, and side effects of different intravitreal immunosuppressants and biologicals that have been studied in literature.

Case report: atypical, unilateral optic nerve infiltration as the first sign of acute lymphoblastic leukemia (ALL) relapse

BACKGROUND

We describe a case of an atypical presentation of leukemic optic nerve infiltration.

CASE PRESENTATION

A patient with acute lymphoblastic leukemia (ALL) in remission suffered from sudden right eye vision loss. At the time of presentation, the affected eye presented with an afferent pupillary defect, while the fundus examination was normal. A complete work up of the patient revealed no signs of ALL relapse, but MR imaging of the optic nerve showed contrast agent uptake consistent with optic nerve infiltration. The patient developed a fulminant ALL relapse and died shortly after. Histology of the optic nerve showed a leukemic infiltration with CD10 positive cells.

CONCLUSIONS

This is the first report of an ALL relapse in the optic nerve without intraocular signs. Patients' medical history should therefore be taken into consideration in patients with unclear vision loss.

Retinal Microvascular Changes in Patients with Acute Leukemia

PURPOSE

To evaluate the retinal circulation in patients with active acute leukemia, to correlate the perfusion metrics with systemic laboratory values, and to assess the vascular perfusion after leukemia remission.

METHODS

Longitudinal study of 22 eyes from 12 patients with acute leukemia; healthy eyes were recruited as controls. All patients underwent optical coherence tomography (OCTA) at baseline. OCTA was repeated in case of morphological leukemia remission.

RESULTS

Patients' age ranged 37-74 years. All participants had a 20/20 vision. In all leukemic eyes, OCTA detected vascular alterations in the macula and the peripapillary region. Vessel density (VD) values in the superficial capillary plexus were lower in leukemia patients than controls (46.8±3.6 vs. 49.2±2%, p=0.08), irrespective of the presence of leukemic retinopathy (7 eyes, 32%). Lower VD was associated with lower white blood cells (p=0.09) and lower platelets (p=0.001). Reappearance of small capillaries, increase in VD, reduction in vessel diameter, and increase in fractal dimension was seen after remission.

CONCLUSION

Subclinical, reversible reduction in vessel density and complexity on OCTA occurs in patients with active acute leukemia and is presumably associated with bone marrow function failure. Further studies are warranted to explore its functional and prognostic significance.

Diagnosis of Acute Promyelocytic Leukemia After Presentation to Neuro-Ophthalmology

BACKGROUND

Acute promyelocytic leukemia (APML) is a medical emergency that can initially present with neuro-ophthalmologic signs. Early recognition is crucial, and immediate treatment with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) can be life-saving. The goal of this study was to describe patients who first presented to neuro-ophthalmology and were subsequently diagnosed with APML.

METHODS

We retrospectively reviewed consecutive patients seen at a tertiary neuro-ophthalmology centre. Patients with an unknown diagnosis of APML at presentation who subsequently went on to receive this diagnosis were included. Clinical characteristics, neuro-ophthalmologic findings, and outcome were retrieved.

RESULTS

A total of 3 patients (2 women and 1 men) with a mean age of 30.7 (range 24-33) years were included in the study. Neuro-ophthalmologic diagnoses at presentation were severe hemorrhagic papilledema related to dural venous sinus thrombosis, hemorrhagic bilateral optic disc edema, and left homonymous hemianopia related to an occipital lobe hemorrhage. At diagnosis, the average hemoglobin was 83.7g/L (range 78-104), and the platelet count was 39.3 × 109/L (range 15-77). All patients were treated with ATRA and ATO. One patient developed papilledema and sixth nerve palsies related to this treatment, which resolved with acetazolamide. Clinical follow-up ranged from 6 to 12 months, and all patients were in clinical remission about systemic APML.

CONCLUSION

Neuro-ophthalmologic symptoms may be the first manifestations of APML, and a complete blood count is an essential test in patients presenting with optic disc edema, especially if hemorrhagic.

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.

Serous retinal detachment as a sign of leukemic choroidopathy: A systematic review

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.

Bilateral retinal artery occlusions as the first manifestation of extramedullary central nervous system involvement in relapsed acute myeloid leukaemia

Retinal artery and vein occlusion are rare devastating complications of central nervous system (CNS) leukaemic infiltrates of the retina and its vasculature. Only a handful of reports exist wherein CNS relapse presents with retinal vascular occlusions. This is usually accompanied by optic nerve swelling and subretinal infiltrates. We present a case of bilateral retinal artery occlusion as a first manifestation of CNS relapse in a patient with acute myeloid leukaemia without optic disc oedema and retinal infiltrates.

A novel OCT signature in leukemic papillopathy masquerading as autoimmune or infectious uveitis

PURPOSE

With therapeutic advances, central nervous system (CNS) involvement in leukemia has become more common. Leukemic optic disc infiltration, often a clinical diagnosis, can present as an isolated finding in primary or relapsed CNS disease and therefore requires early recognition. Not previously well appreciated, we report here signs of intraocular inflammation accompanying leukemic optic disc infiltration, suggesting infectious or non-infectious uveitis as an alternative diagnosis. We describe a novel optical coherence tomography (OCT) sign favoring leukemic infiltration.

METHODS

Retrospective consecutive case series of all leukemic patients with disc edema (5 patients, 6 eyes) presenting to the University of Michigan's Ocular Oncology Clinic between October 2019 and March 2020.

RESULTS

We report five leukemic patients (6 eyes) who were evaluated for disc edema and vitritis and eventually diagnosed with leukemic papillopathy. All five patients initially had a bland lumbar puncture (LP), and all four patients who underwent magnetic resonance imaging (MRI) had no retrobulbar nerve involvement. Clinical findings included preserved visual acuity (n = 5 eyes, 83%), anterior chamber (AC) cell (n = 3 eyes, 50%), vitreous cell (n = 6 eyes, 100%), and retinal whitening (n = 4 eyes, 66%). In five eyes (83%), a diagnosis of infectious or non-infectious uveitis was initially considered. The OCT finding of inner retinal thickening and loss of inner retinal lamination with largely preserved outer retinal architecture helped point towards a leukemic infiltrative process emanating from the disc and spreading retrograde through the nerve fiber layer.

CONCLUSIONS

These cases highlight the difficulty of distinguishing intraocular inflammation associated with leukemic papillopathy from infectious or non-infectious uveitis, especially considering bland LP and negative retrobulbar MRI signal in all our patients. We propose juxtapapillary inner retinal infiltration with the loss of inner retinal lamination and relative preservation of outer retinal architecture on OCT imaging as a finding that supports the diagnosis of leukemic papillopathy.

Ocular surface complications of local anticancer drugs for treatment of ocular tumors

Local chemotherapy is increasingly used, either in combination with surgery or as monotherapy, for management of ocular tumors. Yet many of the local chemotherapeutic agents used for ocular tumors are cytotoxic drugs that are frequently associated with toxicities in normal ocular tissues. Understanding and managing these side effects are important because they affect treatment tolerability, outcome and quality of vision. Herein, we review local anticancer drugs administered for the treatment of ocular tumors, with an emphasis on their toxicities to the ocular surface, adnexa and lacrimal drainage system. We provide the underlying mechanisms and management strategies for the ocular side effects. Recent innovations in anticancer immunotherapy and ocular drug delivery systems also are discussed as new potential therapeutic modalities for alleviation of side effects.