Optic neuropathy in the context of leukemia or lymphoma: diagnostic approach to a neuro-oncologic emergency

Leukemic Optic Neuropathy in Pediatric Patients: A Case Series

PURPOSE

To characterize the presentation, clinical course, and treatment of a series of children with leukemic optic neuropathy.

METHODS

Patients with leukemia who were treated at a tertiary children's hospital for optic nerve infiltration were included (n = 11). Demographic information, cancer history, ophthalmologic examination findings, treatment, and outcomes were retrospectively collected.

RESULTS

Mean age was 10.0 ± 4.8 years, and 63.6% were male and 36.4% were female. The most common underlying oncologic diagnosis was B-precursor acute lymphoblastic leukemia (n = 7, 63.6%). Notably, the majority presented with optic nerve infiltration during presumed remission (n = 9, 81.8%), but 2 patients (18.2%) presented with optic nerve infiltration at their initial leukemia diagnosis. Cerebrospinal fluid was positive for leukemic cells in 36.4% of patients. Magnetic resonance imaging demonstrated optic nerve enhancement and/or enlargement in only 8 patients (72.7%). In addition to other leukemia-directed treatment, 8 patients (72.7%) received emergent local radiation within 1.5 ± 1.2 days of initial ophthalmology examination.

CONCLUSIONS

The largely negative cerebrospinal fluid results and variable magnetic resonance imaging findings in this study emphasize the importance of clinical context for this diagnosis. Clinicians should consider optic nerve infiltration in patients with leukemia and visual or ocular complaints, because urgent treatment is required to preserve vision and manage systemic disease. [J Pediatr Ophthalmol Strabismus. 2024;61(1):67-72.].

Evaluation of visual evoked potential in chronic myeloid leukemias

BACKGROUND

Visual complaint is not very uncommon in chronic myeloid leukemia (CML) patients. Our study aims to evaluate the visual pathway using visual evoked potential (VEP) in cases of CML at the time of diagnosis and 6 weeks after tyrosine kinase therapy, to find out treatment impact in asymptomatic as well as symptomatic individuals and compare it with the general population.

MATERIALS AND METHODS

This is an analytical cross-sectional study. The study group comprised 20 newly diagnosed cases of CML and 20 age- and sex-matched healthy control population. A thorough history and clinical examination with detailed ophthalmological studies, including VEP, were done. Cases who had VEP abnormalities were then followed-up after 6 weeks post-Imatinib therapy and underwent repeat investigations, including VEP.

RESULTS

VEP in cases was significantly deranged (P < 0.001), where 15 patients (75%) had abnormalities in VEP compared to 3 (15%) in control. Post 6 weeks chemotherapy, Out of 10 cases that were followed up, 7 patients had achieved hematological remission with normal VEP finding (P = 0.02). Simultaneously, an increase in hemoglobin (P = 0.002) and reduction in total leukocyte count (TLC) (P = 0.004) were observed.

CONCLUSION

Considerable evidence appear to support the notion that CML patients have a higher prevalence of ophthalmic manifestations as compared to the general population, which can be screened earlier with objective tests like VEP. Concurrently, hematological parameters and VEP showed derangement at the time of diagnosis. After 6 weeks of Imatinib treatment, the improvement in VEP can then be attributed to a reduction in TLC. Hence it can be deduced that VEP has paramount importance in the early identification of ophthalmic manifestations, which are reversible with timely treatment.

Acute lymphoblastic leukemia relapse presenting with optic nerve infiltration

Acute lymphoblastic leukemia is the most common childhood malignancy. Despite many advances in therapy, about 15%-20% of children with acute lymphoblastic leukemia experience a disease relapse. Isolated ocular relapse is relatively rare. A 14-year-old male with T-cell acute lymphoblastic leukemia in remission presented with sudden onset of right eye pain and visual acuity impairment. Fundoscopic examination of the eye and magnetic resonance imaging of the orbits were consistent with optic nerve infiltration. The patient was treated with salvage chemotherapy, orbital radiation and eventual bone marrow transplantation, with notable improvement in vision and regression of retinal and optic nerve findings. Optic nerve infiltration represents an ophthalmic emergency and requires urgent management. The use of radiation therapy is a helpful adjunct with systemic chemotherapy in obtaining disease remission.

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD): current understanding and challenges

New diagnostic criteria for myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) have recently been proposed, distinguishing this syndrome from other inflammatory diseases of the central nervous system. Seropositivity status for MOG-IgG autoantibodies is important for diagnosing MOGAD, but only in the context of robust clinical characterization and cautious interpretation of neuroimaging. Over the last several years, access to cell-based assay (CBA) techniques has improved diagnostic accuracy, yet the positive predictive value of serum MOG-IgG values varies with the prevalence of MOGAD in any given patient population. For this reason, possible alternative diagnoses need to be considered, and low MOG-IgG titers need to be carefully weighted. In this review, cardinal clinical features of MOGAD are discussed. Key challenges to the current understanding of MOGAD are also highlighted, including uncertainty regarding the specificity and pathogenicity of MOG autoantibodies, the need to identify immunopathologic targets for future therapies, the quest to validate biomarkers that facilitate diagnosis and detect disease activity, and the importance of deciphering which patients with MOGAD require long-term immunotherapy.

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.

Isolated Infiltrative Optic Neuropathy in an Acute Lymphoblastic Leukemia Relapse

Optic nerve infiltration as the first sign of isolated central nervous system relapse of acute lymphoblastic leukemia (ALL) is rare. A seven-year-old girl with standard-risk B-cell ALL who was in remission presented with sudden onset of left eye pain and loss of vision. Examination revealed no perception to light in the left eye with positive relative afferent pupillary defect. The optic disc was hyperemic and swollen with total obscuration of the disc margin associated with central retinal artery and vein occlusion. Magnetic resonance imaging of the brain and optic nerve showed left intraorbital optic nerve thickening associated with perineural enhancement and intraconal fat involvement.

Lumbar puncture revealed leukemic infiltration with blast cells after a week of eye symptoms, while bone marrow aspiration was negative for malignant cells. A diagnosis of left leukemic optic nerve infiltration with central retinal artery and vein occlusion was made. A high index of suspicion with repeat cerebrospinal fluid sampling is crucial to confirm the diagnosis as vitreous biopsy may fail to reveal infiltrative cells.

Hypocellular Philadelphia chromosome-positive mixed-phenotype acute leukemia successfully treated with dasatinib: A case report

Both hypocellular leukemia and Philadelphia (Ph) chromosome-positive mixed-phenotype acute leukemia (MPAL) are rare subtypes of leukemia showing unfavorable outcomes and lacking established optimal management. Ph-positive leukemia most often presents with hypercellularity and hypoplasia is a rare condition. The present study reports an extremely rare case of hypocellular biclonal Ph-positive MPAL, which was diagnosed by biopsy and genetic analysis of bone marrow, and successfully treated with dasatinib and steroids. Briefly, a 77-year-old man presented with pancytopenia and flow cytometry of bone marrow could not be evaluated due to hypocellularity. The patient was finally diagnosed with hypocellular Ph-positive MPAL by genetic analysis and immunostaining of bone marrow biopsy. Although blood cells recovered with methylprednisolone pulse administration alone for concurrent optic neuritis, hematopoietic function rapidly normalized with dasatinib administered after definitive diagnosis of Ph-positive leukemia. Dasatinib and oral prednisolone were continued following methylprednisolone pulse administration and the patient achieved molecular complete remission (CR) on day 140 of treatment; molecular CR was maintained thereafter without any severe adverse events. In conclusion, the combination of dasatinib and a steroid may be one of the tolerable treatment options for elderly patients with hypocellular biclonal Ph-positive MPAL. Furthermore, genetic analysis and immunostaining of bone marrow biopsy can help with the diagnosis of leukemia with hypocellular bone marrow.

Radiological Features of Bilateral Sequential Leukaemic Optic Nerve Infiltration: A Case Report

Leukaemic infiltration of the optic nerve is an oncologic emergency that can lead to a significant risk of irreversible vision loss and has an overall poor systemic prognosis. We present the case of a 77-year-old man in previous systemic remission from acute myeloid leukaemia (AML) who developed bilateral sequential leukaemic optic nerve involvement with eventual complete vision loss. A review of the clinical and radiological characteristics of optic nerve infiltration in AML is provided. Profound vision loss to the order of 20/200 or worse is common. Magnetic resonance imaging features include optic nerve thickening, enhancement of the nerve sheath, T2 hyperintensity and restricted diffusion. Urgent orbital radiotherapy is indicated prior to the onset of irreversible optic nerve damage.

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.

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.

Ophthalmic involvement of chronic lymphocytic leukemia: A systematic review of 123 cases

To identify clinical presentations, main causes, and prognosis of ophthalmic involvement in chronic lymphocytic leukemia (CLL), we performed a systematic review of articles describing CLL ophthalmic involvement in January 2019, using the PubMed database. We found 86 articles describing 123 cases of patients with ophthalmic involvement associated with CLL. Ophthalmic symptoms were CLL's first manifestation in 25.6% of patients and revealed Richter transformation in 11.0%. There were three main causes of ophthalmic features: CLL-infiltration (52.0%), lymphoma (26.0%), and infection (15.4%), with specific clinical and radiological characteristics. CLL-infiltration was mostly bilateral, whereas lymphoma was usually unilateral (P = 0.02). Optic neuropathy was always secondary to CLL-infiltration, and in those cases, cerebrospinal fluid immunophenotyping was a potential alternative to invasive biopsy as it confirmed the diagnosis in 4 patients (36.4%). On the contrary, lymphoma usually presented as adnexal involvement (P = 0.04), particularly as an orbital mass (P = 0.004). Infections concerned mostly patients previously treated for CLL (P < 0.0001), and main presentations included posterior uveitis (P = 0.0002) and retinal infiltrates (P < 0.0001). Overall, the prognosis was poor, as 29.3% of the patients died within 36 months of follow-up, and 26.1% had a partial or total visual loss. Eye infections were associated with the poorest prognosis as 47% of patients died, with a 6-month-median survival.

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.

A lot of nerve

A 71-year-old woman with a history of acute lymphoblastic leukemia presented with unilateral optic disc edema. Laboratory evaluations for infectious, inflammatory, and neoplastic etiologies were negative. Magnetic resonance imaging of the orbits with and without contrast demonstrated enhancement and thickening of the right optic nerve with mild stranding of the intraconal fat. She underwent three large-volume lumbar punctures, all of which were negative for malignancy. An optic nerve biopsy was ultimately performed, demonstrating malignant cells on immunohistochemical staining. This case illustrates a rare case of biopsy-proven leukemic infiltration of the optic nerve head as the presenting sign of leukemic relapse despite a negative systemic workup. Leukemic infiltration should be considered in the differential diagnosis for cases of acquired disc edema, especially in patients with a past medical history of leukemia.