Infiltration of the iris in chronic lymphatic leukaemia

Unilateral exudative retinal detachment as the sole presentation of relapsing acute lymphoblastic leukemia

Ocular findings are rarely the initial symptom of leukemia, although up to 90% of all leukemia patients have fundus changes during the course of the disease. Herein we report a relapsing acute lymphoblastic leukemia patient with thesole presentation of sudden visual loss and exudative retinal detachment. An 8-year-old boy with acute lymphoblasticleukemia developed sudden visual loss during his first remission period. Bullous retinal detachment with total afferentpupillary defect was observed. Orbital magnetic resonance imaging revealed an intraocular mass lesion; simultaneouslyobtained bone marrow and cerebrospinal fluid samples showed no evidence of leukemic cells. Following local irradiation,and systemic and intrathecal chemotherapy the mass disappeared. Local irradiation, and systemic and intrathecalchemotherapy effectively controlled the isolated ocular relapse of acute lymphoblastic leukemia and eliminated the needfor enucleation.

Isolated Anterior Chamber Relapse in a Child with Chronic Myeloid Leukemia: Masquerade Syndrome

The authors report a case of anterior uveitis with hypopyon that was refractory to topical corticosteroid therapy. A detailed history revealed that the patient had chronic myeloid leukemia. Cytology in the aqueous humor was consistent with relapse of chronic myeloid leukemia.

Ophthalmic manifestations of acute leukaemias: the ophthalmologist's role

With evolving diagnostic and therapeutic advances, the survival of patients with acute leukaemia has considerably improved. This has led to an increase in the variability of ocular presentations in the form of side effects of the treatment and the ways leukaemic relapses are being first identified as an ocular presentation. Leukaemia may involve many ocular tissues either by direct infiltration, haemorrhage, ischaemia, or toxicity due to various chemotherapeutic agents. Ocular involvement may also be seen in graft-versus-host reaction in patients undergoing allogeneic bone marrow transplantation, or simply as increased susceptibility to infections as a result of immunosuppression that these patients undergo. This can range from simple bacterial conjunctivitis to an endophthalmitis. Leukaemia can present as pathology in the adnexae, conjunctiva, sclera, cornea, anterior chamber, iris, lens, vitreous, retina, choroid, and optic nerve. Recognition of the varied ocular presentations is also important in assessing the course and prognosis of leukaemia. We have presented a systematic approach taking each part of the eye in turn and outlining how leukaemia has been shown to affect it.

Iris and anterior chamber involvement in acute lymphoblastic leukemia

The authors describe a 6-year-old child, with a history of acute lymphoblastic leukemia, who presented with leukemic infiltration of the anterior segment of one eye mimicking anterior uveitis. After tissue diagnosis, administration of radiation therapy to the affected eye resulted in dramatic improvement of the condition. Involvement of the iris and anterior chamber is a recognized but unusual manifestation of leukemia. In the absence of systemic relapse, local radiation therapy without chemotherapy is highly effective, although the prognosis in these patients may be guarded.

Serous retinal detachment in a case with chronic lymphocytic leukemia: no response to systemic and local treatment

Leukemias are systemic hematopoietic neoplasias and not infrequently cause ocular findings. Serous retinal detachment (SRD) is one of these manifestations and even may be the first sign of the underlying leukemia. Here we reported a case with chronic lymphocytic leukemia (CLL) presenting with SRD and discussed the clinical importance and therapeutic options.

Leukemic glaucoma: the effects on outflow facility of chronic lymphocytic leukemia lymphocytes

The purpose of this study was to investigate the mechanisms of the leukemic glaucoma. We established a cell culture from leukemic cells collected from the aqueous humor of a living patient with chronic lymphocytic leukemia (CLL) and glaucoma secondary to the leukemia. We then perfused 16 pairs of fresh cadaver normal human eyes at a constant pressure of 10 mmHg at 37 degrees C. We delivered as a bolus either cultured CLL cells or cultured normal lymphocytes, using 3 x 10(2), 3 x 10(3), 3 x 10(4) or 3 x 10(5) cells in Bárány's solution, into one eye of each pair. The other eye of the pair served as a control, receiving a sham bolus of Bárány's solution alone. In addition, CLL and normal lymphocytes were perfused through 0.2, 0.6, 2, and 3 microns millipore filters. Following perfusion, the tissue and the filters were examined histopathologically by light, transmission and scanning electron microscopy. Cultured leukemic lymphocytes perfused into normal cadaver eyes caused a significantly more profound reduction in outflow facility than normal lymphocytes (P < 0.05); however, there was no significant difference in the effect on outflow facility between leukemic and normal lymphocytes when they were perfused through the millipore filters. Histopathology confirmed the presence of lymphocytes in the trabecular meshwork and Schlemm's canal, deforming on passage through the inner wall. Our results suggest that leukemic lymphocytes in CLL may reduce outflow facility by means of a biological interaction with the tissues of the outflow pathways, rather than by mechanical obstruction due to a lack of distensibility. Questions remain as to the nature of this biological interaction.

Analysis of 135 autopsy eyes for ocular involvement in leukemia

To explain the marked variation in the reported incidence of how often leukemic cells infiltrate the eye in fatal cases of leukemia, we tested the hypothesis that ocular leukemic infiltration is related to the peripheral leukocyte count during the final hours of life. We reviewed tissue sections, as well as autopsy and clinical records, from 135 patients who had fatal leukemia and had their eyes examined after death at Duke University Medical Center. Infiltrates of leukemic cells were found in the eyes of 42 of 135 patients (31.1%), with the choroid being the most frequently involved site. We detected a significant positive correlation between the ocular leukemic infiltration and an agonal leukocyte count as well as the severity of systemic disease. Differences in the agonal circulating leukocyte count may partly explain variations in the incidence of leukemic infiltrates in different postmortem studies.

Leukemic iris infiltration

Three patients with acute lymphoblastic leukemia and leukemic infiltration of the iris are presented. The clinical features, diagnostic techniques, and treatment of this condition are described.

Leukemic iris infiltration as the only site of relapse in a child with acute lymphoblastic leukemia: temporary remission with high-dose chemotherapy

A 12-year-old Caucasian boy developed leukemic hyphema with iris infiltration as the only relapse site during the third complete remission of his acute lymphoblastic leukemia. With high-dose methotrexate, high-dose cytosine-arabinoside plus teniposide, and a 5-week course of vincristine, prednisolone, and L-asparaginase, a complete remission could be achieved. Maintenance treatment was reinstituted for 1 year. However, after stopping the treatment, the iris infiltrate reappeared, and this time the eye was irradiated after chemotherapeutic reinduction. Seven months later, the boy remains in complete remission. The pathogenesis of leukemic iris infiltration is discussed briefly.

Metastatic carcinoma of the iris simulating iridocyclitis

A 46-year-old woman with a history of breast carcinoma and no known metastatic disease presented with iridocyclitis and secondary glaucoma. Intraocular inflammation and pressure elevation persisted despite standard medical therapy, and paracentesis was performed. Cytological examination of the aspirate revealed adenocarcinoma. Subsequent studies disclosed no evidence of extraocular metastasis. Two courses of radiation therapy to the involved eye resulted in a dramatic reduction in intraocular inflammation and allowed temporary control of the intraocular pressure. Ultimately, however, progressive glaucoma necessitated enucleation. This case confirms previous statements that iridocyclitis may be the initial clinical manifestation of metastatic malignancy. In addition, this report emphasises the importance of paracentesis in the diagnostic evaluation of selected cases of anterior uveitis of unknown aetiology.

Ocular and orbital involvement in leukemia

Leukemia may involve almost any ocular tissue, by direct infiltration, by hemorrhage, and by ischemic changes. Both acute and chronic leukemia can cause ocular signs, either initially or later in the disease process; the clinical features and pathologic correlations of this involvement are reviewed. Also, various chemotherapeutic agents used to treat leukemia may cause ocular toxicity. Recently, bone marrow transplants have been performed more frequently in an attempt to prolong patient survival; if graft-versus-host disease results, one symptom is dry eyes from alacrima. Superimposed infection due to immunosuppression can occur from the disease itself or from treatment. Recognition by the ophthalmologist of the various ocular signs is important in assessing the course and prognosis of leukemia.

Leukemic iris infiltration

A 7-year-old boy with acute lymphocytic leukemia developed iris infiltration, blood-streaked hypopyon, and high intraocular pressure. A diagnostic anterior chamber paracentesis was performed, which provided a cytologic diagnosis. The aspirate was studied by both the millipore filter technique with Papanicolaou stain and a dried smear using the Wright's stain. Wright's stain provided more distinct cellular details. Irradiation of the anterior segment resulted in clearing of leukemic iris infiltration, hypopyon, and glaucoma.

Iris involvement in granulocytic sarcoma

A 6-year-old boy with a diagnosis of acute myeoblastic leukemia in remission developed iris infiltration accompanied by uveitis, hypopyon, and vitreous hemorrhage, which was initially unilateral, later becoming bilateral. Pathologically, the eyes showed leukemic infiltrates in the conjunctiva, episclera, sclera, ciliary body, trabecular meshwork, canal of Schlemm, choroid, vitreous, and the iris. Leder stain studies showed positive esterase activity, indicating granulocytic sarcoma. Granulocytic sarcoma may appear intraocularly as iris nodules. These iris nodules may be the initial manifestation of granulocytic leukemia.

Secondary open-angle glaucoma in histiocytosis X

A 9 month-old boy developed secondary open-angle glaucoma associated with fever and multiple lytic bone lesions 2 1/2 months after cataract aspiration. An open bone biopsy provided a diagnosis of histiocytosis X. Hisiocytes similar to those in the bone were identified in a specimen of aqueous humor from the affected eye. No other cells were found. The abnormal histiocytes may have caused the glaucoma by infiltrating the trabecular angle structures and mechanically obstructing aqueous outflow from the eye.

Leukemic ophthalmopathy in children

Abnormalities of the eye were detected in 52 of 657 children (9%) suffering from acute leukemia. The treatment for leukemia was single agent chemotherapy administered sequentially. "Prophylactic" treatment of the central nervous system was not administered. Major manifestations of leukemic ophthalmopathy comprised retinal hemorrhage (in 19) and infiltration of the optic nerve, retina, iris or orbit (29). The ophthalmopathy was treated by topical dexamethasone and radiation therapy. Concurrent bone marrow relapse occurred in most patients. Twenty-seven of 29 patients whose cerebrospinal fluid was examined before or at the time of the onset of leukemic ophthalmopathy demonstrated meningeal leukemia. In contrast, this complication has not been observed in recent patients who received "prophylactic" treatment for meningeal leukemia. Leukemic invasion of the eye should receive appropriate recognition; the posterior pole should be included in the treatment of the central nervous system as a pharmacologic sanctuary.