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Richardson-May J, Musa AM, Suresh P, Sniatecki JJ, Krishnan R. Leukaemic Optic Neuropathy in a Patient with Treated Acute Lymphoblastic Leukaemia: Optical Coherence Tomography as an Aid to Diagnosis. Neuroophthalmology 2024; 48:352-359. [PMID: 39145319 PMCID: PMC11321405 DOI: 10.1080/01658107.2024.2313579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 08/16/2024] Open
Abstract
Leukaemic optic neuropathy is an uncommon cause of visual loss which represents a neuro-oncological emergency with the potential of irreversible blindness if untreated. It can be difficult to diagnose, often presenting with normal neuroradiological and cerebrospinal fluid findings. We present the case of a 26-year-old woman with T-cell acute lymphoblastic leukaemia with optic neuropathy secondary to leukaemic infiltration, who demonstrated features on optical coherence tomography that aided the diagnosis of this condition. This included the presence of numerous, small, hyperreflective opacities erupting from the optic nerve head, which improved following treatment with radiotherapy and chemotherapy, and later recurred when the condition relapsed. This finding may help clinicians differentiate between other causes of optic neuropathy as well as assessing response to treatment and monitoring for recurrence.
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Affiliation(s)
| | - Abdi M. Musa
- Department of Ophthalmology, University Hospital Southampton, Hampshire, UK
| | | | - Jan J. Sniatecki
- Department of Ophthalmology, University Hospital Southampton, Hampshire, UK
| | - Radhika Krishnan
- Department of Ophthalmology, University Hospital Southampton, Hampshire, UK
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2
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Johnson GM, Rossen JL, Simon SS, Weinstein JL, Ralay Ranaivo H, Yoon HH. Leukemic Optic Neuropathy in Pediatric Patients: A Case Series. J Pediatr Ophthalmol Strabismus 2024; 61:67-72. [PMID: 37227013 DOI: 10.3928/01913913-20230331-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
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.].
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Agrawal A, Aggarwal S, Singh R, Goyal J, Garg S. Evaluation of visual evoked potential in chronic myeloid leukemias. Oman J Ophthalmol 2023; 16:489-494. [PMID: 38059114 PMCID: PMC10697254 DOI: 10.4103/ojo.ojo_245_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 07/03/2023] [Accepted: 07/14/2023] [Indexed: 12/08/2023] Open
Abstract
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.
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Affiliation(s)
| | - Sunita Aggarwal
- Department of Medicine, MAMC, LNJP Hospital, New Delhi, India
| | - Ranvijay Singh
- Department of Medicine, MAMC, LNJP Hospital, New Delhi, India
| | | | - Sandeep Garg
- Department of Medicine, MAMC, LNJP Hospital, New Delhi, India
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4
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Dini G, Capolsini I, Cerri C, Massei MS, Mastrodicasa E, Perruccio K, Gorello P, Caniglia M, Verrotti A, Arcioni F. Acute lymphoblastic leukemia relapse presenting with optic nerve infiltration. SAGE Open Med Case Rep 2023; 11:2050313X231175020. [PMID: 37250823 PMCID: PMC10214062 DOI: 10.1177/2050313x231175020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/23/2023] [Indexed: 05/31/2023] Open
Abstract
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.
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Affiliation(s)
- Gianluca Dini
- Department of Pediatrics, University of
Perugia, Perugia, Italy
| | - Ilaria Capolsini
- Pediatric Oncology-Hematology Unit,
Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Carla Cerri
- Pediatric Oncology-Hematology Unit,
Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Maria Speranza Massei
- Pediatric Oncology-Hematology Unit,
Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Elena Mastrodicasa
- Pediatric Oncology-Hematology Unit,
Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Katia Perruccio
- Pediatric Oncology-Hematology Unit,
Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Paolo Gorello
- Department of Chemistry, Biology and
Biotechnology, University of Perugia, Perugia, Italy
| | - Maurizio Caniglia
- Pediatric Oncology-Hematology Unit,
Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Francesco Arcioni
- Pediatric Oncology-Hematology Unit,
Santa Maria della Misericordia Hospital, Perugia, Italy
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5
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Al-Ani A, Chen JJ, Costello F. Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD): current understanding and challenges. J Neurol 2023:10.1007/s00415-023-11737-8. [PMID: 37154894 PMCID: PMC10165591 DOI: 10.1007/s00415-023-11737-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 05/10/2023]
Abstract
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.
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Affiliation(s)
- Abdullah Al-Ani
- Section of Ophthalmology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - John J Chen
- Department of Ophthalmology and Neurology, Mayo Clinic, Rochester, MN, USA
| | - Fiona Costello
- Section of Ophthalmology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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6
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Cameron CA, Juniat V, Tong JY, Crompton JL, Davis G, Patel S, Selva D. Optic nerve infiltration in systemic non Hodgkin lymphoma. Orbit 2023; 42:216-220. [PMID: 34727827 DOI: 10.1080/01676830.2021.1989469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Cassie A Cameron
- Discipline of Ophthalmology and Visual Sciences, The University of Adelaide and the South Australian Institute of Ophthalmology, Adelaide, Australia
| | - Valerie Juniat
- Discipline of Ophthalmology and Visual Sciences, The University of Adelaide and the South Australian Institute of Ophthalmology, Adelaide, Australia
| | | | - John L Crompton
- Discipline of Ophthalmology and Visual Sciences, The University of Adelaide and the South Australian Institute of Ophthalmology, Adelaide, Australia
| | - Garry Davis
- Discipline of Ophthalmology and Visual Sciences, The University of Adelaide and the South Australian Institute of Ophthalmology, Adelaide, Australia
| | - Sandy Patel
- Department of Medical Imaging, Royal Adelaide Hospital, Adelaide, Australia
| | - Dinesh Selva
- Discipline of Ophthalmology and Visual Sciences, The University of Adelaide and the South Australian Institute of Ophthalmology, Adelaide, Australia
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7
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Kuan HC, Mustapha M, Oli Mohamed S, Abdul Aziz RA, Loh CK, Mohammed F, Naffi AA, Othman O, Nasaruddin RA, Alias H. Isolated Infiltrative Optic Neuropathy in an Acute Lymphoblastic Leukemia Relapse. Cureus 2022; 14:e25625. [PMID: 35795502 PMCID: PMC9250751 DOI: 10.7759/cureus.25625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 12/05/2022] Open
Abstract
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.
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8
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Lee S, Fujita K, Wakayama H, Kito Y, Hara T, Tsurumi H. Hypocellular Philadelphia chromosome-positive mixed-phenotype acute leukemia successfully treated with dasatinib: A case report. Mol Clin Oncol 2022; 16:33. [PMID: 34987802 DOI: 10.3892/mco.2021.2466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/25/2021] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Shin Lee
- Department of Hematology and Oncology, Matsunami General Hospital, Gifu 501-6062, Japan
| | - Kei Fujita
- Department of Hematology and Oncology, Matsunami General Hospital, Gifu 501-6062, Japan
| | - Hiroto Wakayama
- Department of Hematology and Oncology, Matsunami General Hospital, Gifu 501-6062, Japan
| | - Yusuke Kito
- Department of Pathology, Matsunami General Hospital, Gifu 501-6062, Japan
| | - Takeshi Hara
- Department of Hematology and Oncology, Matsunami General Hospital, Gifu 501-6062, Japan
| | - Hisashi Tsurumi
- Department of Hematology and Oncology, Matsunami General Hospital, Gifu 501-6062, Japan
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9
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Tong JY, Galanopoulos A, Patel S, Selva D. Radiological Features of Bilateral Sequential Leukaemic Optic Nerve Infiltration: A Case Report. Neuroophthalmology 2022; 46:322-326. [PMID: 36337226 PMCID: PMC9635559 DOI: 10.1080/01658107.2022.2041047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
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.
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Affiliation(s)
- Jessica Y. Tong
- Save Sight Institute, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- CONTACT Jessica Y. Tong Save Sight Institute, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Anna Galanopoulos
- Discipline of Ophthalmology and Visual Sciences, The University of Adelaide and the South Australian Institute of Ophthalmology, Adelaide, Australia
| | - Sandy Patel
- Department of Medical Imaging, Royal Adelaide Hospital, Adelaide, Australia
| | - Dinesh Selva
- Discipline of Ophthalmology and Visual Sciences, The University of Adelaide and the South Australian Institute of Ophthalmology, Adelaide, Australia
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10
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Fortes BH, Dalvin LA, Hogan WJ, Patnaik MM, Choong GM, Salomao DR, Barkmeier AJ, Bhatti MT. Isolated T-cell acute lymphoblastic leukemic optic disc infiltration. Am J Hematol 2021; 96:1717-1718. [PMID: 34559909 DOI: 10.1002/ajh.26357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/07/2021] [Accepted: 09/20/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Blake H. Fortes
- Department of Ophthalmology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Lauren A. Dalvin
- Department of Ophthalmology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - William J. Hogan
- Department of Hematology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Mrinal M. Patnaik
- Department of Hematology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Grace M. Choong
- Department of Hematology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Diva R. Salomao
- Department of Pathology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Andrew J. Barkmeier
- Department of Ophthalmology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - M. Tariq Bhatti
- Department of Ophthalmology Mayo Clinic College of Medicine Rochester Minnesota USA
- Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota USA
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11
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Azarcon CP, Mercado GJV, Alfonso RN. Recalcitrant Optic Nerve and Retinal Infiltration in a Relapse of Acute Lymphoblastic Leukaemia. Neuroophthalmology 2021; 46:126-130. [DOI: 10.1080/01658107.2021.1933079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Corrina P. Azarcon
- Department of Ophthalmology and Visual Sciences, Philippine General Hospital, University of the Philippines – Manila, Manila, Philippines
| | - Gary John V. Mercado
- Department of Ophthalmology and Visual Sciences, Philippine General Hospital, University of the Philippines – Manila, Manila, Philippines
- College of Medicine, University of the Philippines – Manila, Manila, Philippines
| | - Rachelle N. Alfonso
- Division of Hematology, Department of Medicine, Philippine General Hospital, University of the Philippines – Manila, Manila, Philippines
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12
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Bouffard MA, Chwalisz BK, Romero JM, Arrillaga-Romany IC, Massoth LR. Case 6-2021: A 65-Year-Old Man with Eye Pain and Decreased Vision. N Engl J Med 2021; 384:745-753. [PMID: 33626257 DOI: 10.1056/nejmcpc2027089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Marc A Bouffard
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Bart K Chwalisz
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Javier M Romero
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Isabel C Arrillaga-Romany
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Lucas R Massoth
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
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13
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Chamberlain PD, Dermarkarian CR, Woodland MB, Allen RC, Al-Zubidi N. Optic nerve biopsy in leukemic infiltrative optic neuropathy: a case report and review of the literature. Orbit 2021; 41:480-484. [PMID: 33557696 DOI: 10.1080/01676830.2021.1880443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Paul D Chamberlain
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA
| | | | - M Brent Woodland
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Richard C Allen
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA.,Department of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nagham Al-Zubidi
- Department of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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14
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McInnis-Smith K, Mansueto LA, Schafernak K, Jacobsen J, Henry MM, Ramasubramanian A. Isolated optic nerve leukemic relapse diagnosed via fine needle aspiration biopsy and transconjunctival biopsy. Pediatr Blood Cancer 2021; 68:e28684. [PMID: 32886399 DOI: 10.1002/pbc.28684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | - Michael M Henry
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona
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15
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A novel OCT signature in leukemic papillopathy masquerading as autoimmune or infectious uveitis. Graefes Arch Clin Exp Ophthalmol 2021; 259:1315-1322. [PMID: 33394161 DOI: 10.1007/s00417-020-05055-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/07/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022] Open
Abstract
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.
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16
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Delestre F, Blanche P, Bouayed E, Bouscary D, Mouthon L, Brezin A, Le Jeunne C, Chaigne B. Ophthalmic involvement of chronic lymphocytic leukemia: A systematic review of 123 cases. Surv Ophthalmol 2020; 66:124-131. [PMID: 32407752 DOI: 10.1016/j.survophthal.2020.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Florence Delestre
- Service de Médecine Interne, Centre de Référence Maladies systémiques auto-immunes rares d'Ile de France, Hôpital Cochin, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Philippe Blanche
- Service de Médecine Interne, Centre de Référence Maladies systémiques auto-immunes rares d'Ile de France, Hôpital Cochin, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Emna Bouayed
- Service d'ophtalmologie, Hôpital Cochin, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Didier Bouscary
- Service d'hématologie, Hôpital Cochin, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Luc Mouthon
- Service de Médecine Interne, Centre de Référence Maladies systémiques auto-immunes rares d'Ile de France, Hôpital Cochin, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Antoine Brezin
- Service d'ophtalmologie, Hôpital Cochin, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Claire Le Jeunne
- Service de Médecine Interne, Centre de Référence Maladies systémiques auto-immunes rares d'Ile de France, Hôpital Cochin, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Benjamin Chaigne
- Service de Médecine Interne, Centre de Référence Maladies systémiques auto-immunes rares d'Ile de France, Hôpital Cochin, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
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Stage IV Small Lymphocytic Lymphoma Presenting with Unilateral Vision Loss. Case Rep Oncol Med 2020; 2020:3752409. [PMID: 32047683 PMCID: PMC7001663 DOI: 10.1155/2020/3752409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 12/16/2019] [Accepted: 12/28/2019] [Indexed: 11/25/2022] Open
Abstract
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.
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Birnbaum FA, Meekins LC, Srinivasan A, Murchison AP. A lot of nerve. Surv Ophthalmol 2019; 65:272-277. [PMID: 31029580 DOI: 10.1016/j.survophthal.2019.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 04/15/2019] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Faith A Birnbaum
- Department of Ophthalmology, Duke Eye Center, Durham, North Carolina, USA
| | - Landon C Meekins
- Department of Ophthalmology, Duke Eye Center, Durham, North Carolina, USA.
| | - Archana Srinivasan
- Skull Base Division, Neuro-ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Ann P Murchison
- Skull Base Division, Neuro-ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA; Director, Wills Eye Emergency Department, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
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