Ophthalmic manifestations of acute and chronic leukemias presenting to a tertiary care center in India

Highlights of ophthalmological manifestations in newly diagnosed acute leukemia: a correlation with hematological parameters

Acute leukemia is a hematological malignancy affecting different organ systems including the eye and orbit through direct infiltration of tissues or secondary to hematological abnormalities. Ophthalmological manifestations in acute leukemia are variable ranging from asymptomatic presentation to serious manifestations that can alter the disease course and treatment. The purpose of this study is to detect the incidence of different ophthalmological manifestations in newly diagnosed acute leukemia patients and to assess the relationship between ocular findings and hematological characteristics and the sequel of these neoplasms. A cross-sectional study with analytical components was conducted on 222 newly diagnosed acute myeloid and acute lymphoblastic leukemia patients who presented at Oncology Center Mansoura University (OCMU) between January 2022 and February 2023. All patients underwent a complete ophthalmic evaluation at Mansoura Ophthalmology Center (MOC). The mean age was 43.45 ± 17.35 years (range, 17-85), and M/F was 137 (61.7%)/85 (38.3%). One-hundred and forty-four (64.9%) had acute myeloid leukemia (AML), and 78 (35.1%) had acute lymphoblastic leukemia (ALL). Ophthalmic manifestations were detected in 96 patients (43.2%). Among them, 4 (1.8%) had poor visual acuity. Retinal hemorrhage (19.8%) and Roth spots (17.1%) were the most common ocular manifestations. Other ophthalmological manifestations observed were orbital involvement (3.2%), ocular motility issues (1.4%), subconjunctival hemorrhage (5.9%), conjunctival chemosis (0.9%),lid swelling (4.1%), lid ecchymosis (3.2%), lagophthalmos (0.5%), lid ptosis (1.8%), retinal venous congestion & tortuosity (4.1%), preretinal hemorrhage (3.2%), vitreous hemorrhage (3.2%), macular affection (2.3%), retinal infiltration (1.8%), exudative retinal detachment (ERD) (1.8%), cotton-wool spots (0.9%), retinal vein occlusion (0.5%), papilledema (2.8%), optic disc infiltration (1.8%), disc pallor (1.8%).AML patients were significantly associated with a higher frequency of ocular affection, retinal hemorrhages, and Roth spots (P 0.028, 0.003, and 0.046, respectively) compared to ALL patients. Retinal hemorrhage was statistically significantly associated with anemia (P 0.021). Ophthalmological manifestations of acute leukemia are heterogeneous; they can be detected at initial presentations or relapse. Some manifestations are asymptomatic, others can affect visual acuity or even alter the disease course. Cooperation between ophthalmologists and haemato-oncologists is crucial for recognizing ocular involvement and disease management.

Ophthalmic manifestations in hematological malignancies: An observational study from a tertiary care health center in Eastern India

PURPOSE

This study aimed to document the spectrum of ocular manifestations of hematological malignancies presenting to a tertiary health center in Eastern India and their association with blood parameters.

METHODS

This hospital-based cross-sectional study was conducted from August 2021 to July 2022. Patients diagnosed with leukemia, lymphoma, and multiple myeloma were enrolled in the study. A comprehensive ophthalmic evaluation was done in each case.

RESULTS

A total of 97 patients with a confirmed diagnosis of hematological malignancies and meeting the inclusion and exclusion criteria were included in the study. Ocular manifestations were noted in 48 (49.48%) patients. Acute lymphocytic leukemia accounted for 35.4% of cases, followed by acute myeloid leukemia (31.25%), lymphoma (4.2%), and minimum manifestation in multiple myeloma (2.1%) patients. Among 48 patients with ocular manifestations, anterior segment involvement was found in 6.2% of cases, with subconjunctival hemorrhage being the most common, and the posterior segment was involved in 100% of patients, with intraretinal hemorrhages being the most common manifestation. A statistically significant association was noted between hemoglobin, total red blood cell count, and total platelet count with posterior segment manifestations ( p < 0.001). On multivariable logistic regression, only total leucocyte count and total platelet count were significant predictors for ocular manifestation.

CONCLUSION

Indirect involvement of the retina is the most common ocular pathology in hematological malignancies, with intraretinal hemorrhages being the most common finding. Ophthalmic examination is highly recommended as a part of the routine evaluation at the time of diagnosis of hematological malignancies and periodically thereafter to diagnose any ocular involvement.

Navigating the Uncharted: A Rare Case of Ocular Flutter and Intermittent Jaw Movements in a Case of Chronic Lymphoid Leukemia

Although chronic lymphocytic leukemia (CLL) is the most common leukemia in the Western world, neurologic complications arising from direct leukemic involvement of the nervous system are reported in only 1% of patients with CLL. Ocular involvement in CLL, direct or indirect, is less known and exceptionally rare. This case involves a 63-year-old female with CLL undergoing chemotherapy for a year, who recently presented with unusual eye movements in the horizontal plane (ocular flutter), resting and intentional tremors in the right upper and lower limbs, and intermittent jaw movements. With no established protocol for CLL with central nervous system involvement, collecting case data becomes crucial for determining optimal treatment and diagnostic approaches early on.

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.

Increased peripapillary capillaries in patients with acute leukemia by using optical coherence tomography angiography

PURPOSE

To evaluate the radial peripapillary capillary vessel density (RPC-VD) and thickness of the retinal nerve fiber layer (RNFL) in acute leukemia (AL) and the associations of these characteristics with blood laboratory parameters.

METHODS

A cross-sectional study was performed at the Ophthalmology Department of the Sun Yat-sen Memorial Hospital from February 2019 to April 2022. Sixty eyes of 30 patients diagnosed with AL and sixty eyes of 30 matched healthy controls were included. Optical coherence tomography angiography (OCTA) in the 4.5-mm Angio Disc scan mode and the Ganglion cell complex scan mode were performed for all participants. Correlation analyses were used to examine the associations of RPC-VD and RNFL with blood laboratory parameters.

RESULTS

Patients in the AL group had significantly increased RPC-VD in the whole-image (51.42±0.35 vs. 49.52±0.36) and peripapillary fields (53.90±0.43 vs. 51.17±0.50) compared with people in the control group (all P<0.001), while no difference was found for RPC-VD in the inside optic disc fields in the two groups. The RNFL in the AL group was significantly thicker than that in the control group (131.10±3.89 μm vs. 115.03±2.22 μm, P<0.05). Complete blood count (CBC) parameters, including red blood cells, hemoglobin and hematocrit, had a significant negative correlation with RPC-VD and RNFL (all P <0.05).

CONCLUSION

An increased RPC-VD and a thicker RNFL are evidence of fundus changes in patients with early-stage AL, and these metrics may be related to decreases in red blood cells, hemoglobin and hematocrit.

Leukemic retinopathy presenting as concurrent bilateral subhyaloid hemorrhage and subarachnoid hemorrhage in a patient with acute monocytic leukemia: a case report

BACKGROUND

Ophthalmic manifestations are common in patients with leukemia, developing in nearly 50% of cases. Intracranial hemorrhage is another potentially fatal complication of leukemia. In this case report, we aim to present a challenging case that involves both ophthalmic and intracranial manifestations in an individual with acute monocytic leukemia.

CASE PRESENTATION

A 36-year-old Persian male presented to the emergency room with complaints of fever, headache, and bilateral blurred vision. The patient had been diagnosed with acute monocytic leukemia 3 months prior and had undergone four sessions of induction chemotherapy, the last of which was 10 days prior to admission. The patient was admitted to the internal medicine service, and initial lab studies confirmed pancytopenia, including severe neutropenia, anemia, and thrombocytopenia. Subarachnoid hemorrhage in the left frontal lobe was detected through spiral brain computed tomography scan. Ophthalmic examination revealed visual acuity of light perception in the right eye and 3-m finger count in the left eye. Fundus examination revealed bilateral peripapillary subhyaloid and intraretinal hemorrhages, confirming leukemic retinopathy. The patient showed significant improvement in visual acuity and hemorrhage resolution through conservative treatment and regular follow-ups after 3 months.

CONCLUSION

Simultaneous subarachnoid hemorrhage and bilateral subhyaloid hemorrhages seemed to have occurred as a result of pancytopenia. Management approach of ophthalmic manifestations of leukemia involves interdisciplinary cooperation and should be individualized on the basis of the patients' underlying medical condition.

Ophthalmic Manifestations of Newly Diagnosed Acute Leukemia Patients in a Tunisian Cohort

Purpose

To describe ocular manifestations of acute leukemia in a Tunisian cohort and to assess the associations between ophthalmic findings and epidemiological, clinical, and biological features of the disease.

Methods

A prospective study included patients newly diagnosed with acute leukemia referred to our clinics between January 2019 and July 2020. All patients underwent a complete ophthalmic evaluation and spectral-domain optical coherence tomography (SD-OCT) at presentation, then every two months during one year. We defined two groups: Group 1 included patients with leukemic ophthalmopathy and group 2 included patients with normal ophthalmic examination.

Results

Forty-six patients were enrolled. The mean age of patients was 32.1±15.3 years. The sex ratio M/F was 1.55 (28 male patients and 18 females). Twenty-nine patients (63%) had acute myeloid leukemia (AML), and 17 (37%) had acute lymphoblastic leukemia (ALL). The average follow-up was 9.1 months (range: 3–12 months). We observed ophthalmic manifestations in 28 patients (61%). Among them, 17 (61%) had vision-threatening complications. The posterior segment was the most common site of ocular involvement (82% of group1). Primary leukemic infiltration (Disc edema, ptosis, exophthalmos) was present in 13 eyes (14.1%). Twenty-seven eyes (29.3%) had secondary involvement lesions (Subconjunctival hemorrhage, periorbital ecchymosis, retinal/sub-hyaloid hemorrhage, dilated/tortuous veins). Twenty-one eyes (22.8%) showed other ocular manifestations which etiopathogenesis is not yet fully understood (White-centred hemorrhages, cotton-wool spots, serous retinal detachment, hemorrhagic pigment epithelial detachment). Leukemic retinopathy was significantly more frequent in adults (23/39 and 1/7 in adult and pediatric groups, respectively; p=0.003). Patients suffering from AML were more likely to have secondary ocular involvement (20/29 and 7/17 in AML and ALL patients, respectively; p=0.047). Retinal hemorrhages were statistically associated with anemia and thrombocytopenia (p=0.041 and p=0.034; respectively).

Conclusion

Leukemic ophthalmopathy seems to be frequent and may lead to severe visual impairment. An ophthalmic assessment complemented with SD-OCT has paramount importance in all newly diagnosed acute leukemic patients.

Ocular findings in children with acute leukemia at a tertiary care center in South America

PURPOSE

The purpose of this study was to evaluate ophthalmological findings in patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) in a Latin American population.

MATERIALS AND METHODS

This was a single-center, retrospective study. The observational analysis was conducted in AML and ALL patients seen as a routine examination at the department of ophthalmology of tertiary care center in Argentina between March 1, 2017, and February 28, 2018.

RESULTS

Overall, 137 patients with acute leukemia were included. The mean age was 7.9 ± 5.2 years (0-18), and 55% were male (n = 75) and 45% female (n = 45). At least one-fifth (n = 31) of the patients presented some type of ocular manifestation (23%). The most frequently observed manifestation was retinal hemorrhages (n = 14), followed by papilledema (n = 9) and ocular surface involvement (n = 5). The eye involvement was more frequently identified in the AML group (24%), compared to the ALL group (22%), especially papilledema with central nervous system compromise ALL (5%) and AML (11%), P < 0.01. The presence of hemorrhages was similar in both groups. In patients with retinal hemorrhage (n = 14), the mean hematological findings were hemoglobin 7.4 ± 0.4 g/dL (6.5-8.0), erythrocytes 2.5M ± 0.3/mm³ (confidence interval [CI], 2.0-3.1), and platelets 76,000 ± 32,000/mm³ (CI, 8000-384,000). Patients without retinal findings (n = 123), the mean hematological findings were hemoglobin 9.1 ± 0.6 g/dL (8.0-10.2), erythrocytes 3.2M ± 0.6/mm³ (CI, 2.5-3.5), and platelets 92,000 ± 44,000/mm³ (CI, 42.000-390.000). Multivariable analysis found that hemoglobin levels were the most reliable predictive factor for retinal findings. It was observed that the risk diminishes in patients with levels higher than 8.5 g/dL, and that it increased in patients with levels ranging between 6.5 and 7.5 g/dL at least twice (P < 0.01).

CONCLUSIONS

Our results show that ocular involvement occurs in a high percentage of patients with leukemia with a clear clinical, humoral, and sometimes prognostic correlation, suggesting routine ophthalmologic evaluation in these patients.

Acute Unilateral Hypopyon Uveitis and Secondary Glaucoma in an Adult With Relapsing Acute Lymphoblastic Leukemia

Anterior segment infiltration in acute lymphoblastic leukemia (ALL) presenting as hypopyon uveitis in an adult is rare. We report this case as an uncommon presentation in a patient in remission after chemotherapy for ALL. In addition to the hypopyon, the patient presented with congested eye caused by secondary raised intraocular pressure. There is a need to maintain a high index of clinical suspicion in uveitis cases, as early diagnosis of ocular malignancy can save vision. Atypical unilateral hypopyon, even in adults, can be an indication of relapsing ALL.

Ocular Manifestations of Newly Diagnosed Acute Leukemia Patients

Purpose

To present primary ocular manifestations in acute leukemia.

Methods

This cross-sectional descriptive hospital-based study evaluated all newly diagnosed leukemia patients of three referral hospitals of Tehran University of Medical Sciences in 2015-2016 and Mahak Hospital in Tehran in 2017. Exclusion criteria included the patients with the previous history of chemotherapy, cases of relapsing disease, and the patients with a history of ocular disease or other systemic conditions with ophthalmic manifestations.

Results

A total of 85 patients (170 eyes) were evaluated in our study, including 29 children (34.1%) and 43 females (50.6%). The mean patient age was 37.84 ± 11.91 years in the adult group and 6.28 ± 4.70 years in the pediatric category. Ophthalmic involvement was seen in 27 patients (31.8%), including 6 pediatric patients (20.7%) and 21 adult patients (37.5%). Two patients (2.3%) had direct infiltration by leukemic cells and 76 patients (89.41%) of patients were asymptomatic. There was a correlation between ophthalmic involvement and platelet count and hemoglobin level. In patients with ocular signs, higher mortality rates were observed.

Conclusions

At the time of diagnosis in acute leukemia patients, complete ophthalmic evaluation including dilated fundus examination is suggested as ocular involvement in these patients is common and sometimes asymptomatic. Ophthalmic involvement in leukemic patients should be identified in a timely manner, particularly in individuals with low platelet counts and hemoglobin levels, due to the potential prognostic relevance.

Ophthalmic Manifestations in Acute Leukemia Patients and Their Relation With Hematological Parameters in a Tertiary Care Center

Background: Leukemia is a neoplastic disorder that affects blood and bone marrow and is characterized by white blood cells' abnormal proliferation. Leukemia patients may present with different ophthalmic manifestations. This study aims to provide an updated data about the prevalence and types of ocular manifestations in acute leukemia patients and their relation with the hematological parameters.

Methods: This retrospective cross-sectional study included all acute leukemia patients diagnosed from 2015 to 2020 and underwent an ophthalmic examination during this period at King Abdulaziz Medical City in Jeddah.

Results: Eighty-one patients met the inclusion and exclusion criteria and had ophthalmic examinations. Forty-three (53.1%) patients were males, and 38 (46.9%) patients were females. Acute lymphocytic leukemia (ALL) was diagnosed in 55 (67.9%) patients, while acute myelogenous leukemia (AML) was diagnosed only in 26 (32.1%). Ophthalmic manifestations were observed in 23 patients with a prevalence of 28.4%. AML patients had more manifestations with a rate of 38.5%. ALL had a rate of 23.6% (p=0.1). Retinal hemorrhage was the most commonly seen manifestation in six patients.

Conclusion: Ophthalmic manifestations are not uncommon in acute leukemia patients. Low hemoglobin and RBC could give an idea about the type of ophthalmic manifestation, not the presence or absence. It is highly recommended to examine acute leukemia patients routinely prior, during, and after the treatment to prevent serious ocular damage and monitor the course of the disease.

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 presenting sign of acute lymphoblastic leukemia: A case report and literature review

Purpose

To describe a unique case of unilateral serous retinal detachment as the presenting sign of B-cell acute lymphoblastic leukemia (ALL).

Observations

A 74 year old woman presented with right eye blurry vision and was found to have an underlying serous retinal detachment, along with cotton wool spots, inner retinal hemorrhages, and retinal pigment epithelial changes throughout her bilateral fundi. Fluorescein angiography demonstrated bilateral vasculitis and ultrasonography revealed asymmetric thickening and enhancement of the affected eyes’ choroid. This prompted a systemic lab workup and results were suspicious for an underlying hematologic malignancy. The patient was admitted to the hospital for bone marrow biopsy confirming B-cell ALL, underwent intensive intravenous and intrathecal chemotherapy, and was discharged one month later. Follow up appointment in the ophthalmology clinic demonstrated functional and anatomic improvement in the serous retinal detachment and choroidal thickening suggestive of infiltration in her right eye.

Conclusions

SRDs are an uncommon ocular manifestation of leukemia, and even less common as a presenting sign of the disease. A comprehensive literature review demonstrated 11 other cases reported worldwide. We present the first such case with additional findings of leukemic retinopathy, optic nerve and choroidal infiltration, and vasculitis, as well as a complete library of ophthalmic imaging from the patient's initial presentation.

Importance

A new diagnosis of serous retinal detachment(s) without any obvious cause should raise suspicion for leukemia and prompt further workup. Early recognition of this hematologic malignancy is crucial for prompt initiation of life-saving therapy.

Acute myeloid leukemia presenting as horizontal diplopia

Acute myeloid leukemia (AML) accounts for 16% of all leukemias in children. Prognosis in the pediatric population is better than that of older populations, with a younger age at diagnosis being a favorable prognostic factor [1]. Diplopia is a rare first presenting sign of AML. We present a 15 year old male complaining of diplopia and unilateral orbital swelling. Workup in the emergency department found normal neuroimaging but revealed a markedly elevated leukocytosis with anemia and thrombocytopenia. Peripheral smear showed increased blast cells >10%. This patient was ultimately diagnosed with AML. This case demonstrates an atypical presentation of AML and urges a thorough work up for patients presenting with unexplained diplopia.

Ophthalmological findings in patients with leukaemia in a Colombian population

OBJECTIVE

To report the ocular manifestations in patients with leukaemia.

METHODS

This is a retrospective, descriptive and observational study in patients with ocular manifestations of leukaemia.

RESULTS

A total of 14 eyes were evaluated corresponding to 8 patients (5 women and 3 men) with ocular manifestations of leukaemia. The mean age at diagnosis was 43 years (31-76 years). Six eyes corresponded to patients with acute myeloid leukaemia (AML), four eyes to acute lymphoid leukaemia (ALL), two eyes to chronic myeloid leukaemia (CML), and the remaining two belonged to patients with hairy cell leukaemia (HCL). The primary ocular findings were choroidal invasion in 12 eyes (85.7%), retinal infiltration in 4 eyes (28.6%), and neuro-ophthalmic disorders in 4 eyes (28.6%). The mean visual acuity improved from 0.689 to 0.449 (logMAR) (P=.012) after the systemic and intrathecal chemotherapy. Of the eight patients, four died from systemic complications of the underlying disease.

CONCLUSIONS

This is the first report of multiple ocular manifestations secondary to leukaemia in a Colombian population. It is important to keep in mind that this disease is included within the masquerade syndromes and that the ophthalmological findings that, while subtle, can also be devastating and be signs of a life-threatening disease.

Unilateral Proptosis As An Initial Sign Of Acute Myeloid Leukemia In A Child: A Case Report

Granulocytic sarcoma (chloroma) is a rare malignant solid tumor representing an extramedullary manifestation of acute myeloid leukemia (AML). Rarely, a chloroma can develop as the sole manifestation and its appearance may precede the systemic manifestations of acute myelocytic leukemia by months to years. We report a rare case of unilateral orbital mass presenting with progressive proptosis involving left globe in an otherwise healthy child, and give a brief overview of the literature about this unusual presentation. Leukemic infiltration should be considered in the differential diagnosis of orbital masses and proptosis even in the absence of systemic manifestations of AML. Early detection and management are crucial to preserve vision and prevent complications.

Ocular manifestations of leukaemia: A teaching hospital experience

Background

Knowledge of the ophthalmic manifestations of leukaemia is important not only because of the frequency with which changes are seen but because the eye often reflects the disease state of the illness, and once identified, prompt referral, early treatment can be instigated, blindness can be averted and a life may be saved. These manifestations are often overlooked because of the underestimation of the magnitude of the ocular sequelae which may be blinding.

Aim

This study aims to describe the ophthalmic findings in adult leukaemic patients at two teaching hospitals in Lagos, Nigeria.

Patients and Methods

This was a clinic-based, comparison multicentre study conducted at Lagos University Teaching Hospital and Lagos State University Teaching Hospital over a 9-month period of May 2012-January 2013. The cases were newly diagnosed leukaemic patients (acute and chronic) from the haematology clinics. Controls were escorts of apparently normal patients. Detailed ocular examination was carried out after written informed consent was obtained. Analysis was done using SPSS 17.

Results

A total of 160 eyes in 80 individuals examined comprised forty cases and forty controls. The results of the cases were compared with the age- and sex-matched controls. Leukaemic-related ophthalmic manifestations were present in 56 eyes (70.0%) of the cases studied. Findings in cases were periorbital oedema in 8 eyes (10%), subconjunctival haemorrhage in four eyes (5%), intraretinal haemorrhage as found in 25 eyes (31.3%), retinal venous tortuosity in 21 eyes (26.3%), Roth spots in 19 eyes (23.8%) and retinal infiltrates in 17 eyes (21.3%).

Conclusion

Ophthalmic disorders occur in adult patients living with leukaemia. Prompt initial and periodic ophthalmic evaluation is recommended in all leukaemic patients.

Retinal and Preretinal Hemorrhages in a Patient Receiving Hyper-CVAD Chemotherapy for T-Cell Acute Lymphoblastic Leukemia

Hyperfractionated cyclophosphamide, vincristine, adriamycin, and dexamethasone (Hyper-CVAD) is an important chemotherapeutic regimen for acute lymphoblastic leukemia (ALL) and non-Hodgkin's lymphoma. We present a case of a 23-year-old male with T-cell ALL and visual acuity of 20/20 in the right eye and 20/25 in the left eye who developed significant changes in his vision after starting Hyper-CVAD therapy. The patient initially presented with cotton wool spots in the fundus shortly after starting the regimen. After going through the induction phase of chemotherapy, he had a sudden decline in his vision to light perception in the left eye. Posterior segment exam revealed retinal ischemia and multilayered hemorrhages in both eyes as well as a large preretinal hemorrhage obscuring the fovea in the left eye. Labs associated the appearance of these hemorrhages with a significant decrease in hemoglobin and a platelet count of 5 K/μL. A Nd:YAG laser applied in the left eye at the posterior hyaloid face allowed blood to drain into the vitreous cavity and brought the patient's visual acuity back to baseline. Hyper-CVAD is an aggressive chemotherapy regimen that can cause severe thrombocytopenia secondary to myelosuppression. Frequent retinal evaluations and timely intervention is advisable in these cases as extensive intraretinal hemorrhages may cause irreversible damage.

Ophthalmic Manifestations of Acute Leukemia

Introduction Ocular involvement in leukemia may occur because of direct leukemic infiltration or because of secondary ophthalmic involvement as a result of abnormalities related to blood like anemia, thrombocytopenia, and leukocytosis. In some patients with leukemia, ophthalmic signs can precede the systemic features and can help in early diagnosis of systemic leukemia. Due to the scarcity of data on this topic from Pakistan, we conducted this study to determine the pattern of ocular involvement in patients with leukemia presenting in our settings. Methods This cross-sectional study was conducted in a tertiary care hospital of Pakistan over a period of one year. The study comprised of both newly diagnosed and follow-up patients of acute leukemia of age more than 15 years. Patients underwent detailed ophthalmic anterior and dilated posterior segment examination. Patient's demographic profile, type of leukemia, chemotherapy status, and hematologic findings were also documented. Results There were 97 leukemic patients in the study with 55 (56.7%) males and 42 (43.3%) females. Various ophthalmic manifestations were observed in 47 (48.45%) patients. Forty-two (43.3%) were diagnosed cases with acute lymphocytic leukemia (ALL) and 55 (56.7%) suffered from acute myelogenous leukemia (AML). Ophthalmic manifestations were present in 29 patients of AML (52.7%) and 18 patients of ALL (42.85%). Ocular involvement was significantly more common in newly diagnosed (n=32) as compared with follow-up patients (n=15) (p-value = 0.032). Posterior segment (n=48) was the most common site of ocular involvement (n=48, 49.5%) with retinal hemorrhages seen in 40 patients (41.2%) and papilloedema in seven cases (7.2%). Thirty-three (70.2%) out of 47 patients with ophthalmic manifestations were asymptomatic while 14 (29.8%) had ocular symptoms at the time of initial presentation. Conclusion Ophthalmic manifestations were present in about half of the patients with leukemia. Ocular involvement was more prevalent in newly diagnosed cases and in patients with AML.

Bilateral Proptosis in a Child: A Rare Presentation of Acute Lymphoblastic Leukemia

Purpose

Acute lymphoblastic leukemia (ALL), a common hematological malignancy observed in children, typically presents with fever, pallor, easy bruising, hepatosplenomegaly and lymphadenopathy. However, when ALL manifests with unusual signs and the blood counts and peripheral smears are normal, it causes a diagnostic dilemma.

Case Report

We report a 5-year-old boy who presented with bilateral proptosis as the initial manifestation of ALL. He presented with fever and bilateral knee pain attributed to a fall while playing. There was a history of progressive bilateral proptosis for a 3-month period not associated with any other complaints such as fever, eye pain, redness, or tearing. Thyroid function tests were normal. Blood counts acquired upon proptosis presentation were normal. When he presented to us three months later, blood counts revealed a pancytopenia but the peripheral smear showed no abnormal cells. Magnetic resonance imaging of the brain and orbits was normal. Bone marrow aspirate flow cytometry confirmed the diagnosis of B cell acute lymphoblastic lymphoma.

Conclusion

Ophthalmologists should be aware of the unusual ophthalmologic manifestations of acute leukemia, as they may precede overt leukemia and cause diagnostic dilemmas. Knowledge about the rare and isolated extramedullary manifestations of ALL facilitates early diagnosis and thereby improves prognosis.

Bilateral Conjunctival Infiltration as an Extramedullary Relapse of AML

Acute myelogenous leukemia (AML) accounts for 1.2% of all cancer deaths. Relapse is the major cause of treatment failure in acute myeloid leukemia (AML) patients. AML rarely presents as ocular manifestation in relapse or at presentation. The M4 subtype of AML is most commonly presented with extramedullary involvement. In this report, we presented a young female with AML who was diagnosed and treated for AML about 40 months ago. She did not transplant because she did not have a full-match donor. About 4 months ago, she visited with a red eye and conjunctival infiltration. She was referred to an ophthalmologist for a biopsy, and the pathology report showed the relapse of AML which was treated with systemic chemotherapy. Red eyes with subconjunctival nodules in patients with a history of previous AML should raise the suspicion for recurrent disease that warrants urgent biopsy and systemic treatment. Eye involvement with leukemia is usually responsive to systemic chemotherapy.

Bilateral Optic Nerve Involvement Combined with Unilateral Facial Palsy in a Patient with Acute Myeloid Leukaemia: A Case Report

Central nervous system (CNS) involvement, including optic nerve involvement, in a patient with acute myeloid leukaemia (AML) is an extremely rare condition. We report a case of bilateral optic nerve involvement combined with unilateral facial palsy in a patient with AML who achieved complete remission following allogenic peripheral blood stem cell transplantation as a young patient. After further evaluation, the patient was diagnosed with a recurrence of AML with CNS involvement. The presentation of multiple types of CNS involvement in AML may be suspicious evidence of AML recurrence.

Ocular Manifestations in Leukemias and Their Correlation with Hematologic Parameters at a Tertiary Care Setting in South India

PURPOSE

To determine the prevalence of ocular manifestations and the association of these manifestations with hematologic parameters among patients with leukemia attending a hemato-oncology unit at a tertiary care government hospital in South India.

DESIGN

This was a cross-sectional observational study.

PARTICIPANTS

All patients attending a hemato-oncology unit at a tertiary care government hospital in South India who were diagnosed with acute or chronic leukemia that was confirmed by a bone marrow biopsy.

METHODS

Consecutive patients with leukemia presenting at the hematology clinic underwent standardized leukemia blood workup and comprehensive ophthalmic evaluation. Patient demographics, the type of leukemia, ophthalmic features, and hematological parameters such as hemoglobin level, white blood cell count, and platelet counts were recorded. The association between ophthalmic manifestations and blood counts was analyzed using multivariable regression analysis.

MAIN OUTCOME MEASURES

The study measured the prevalence of various ocular manifestations in different types of leukemias and their association with hematologic parameters.

RESULTS

In total, 133 eyes of 133 patients were examined during the study period. The prevalence of leukemic ophthalmopathy was found to be 68% in cases of acute myeloid leukemia, 42% in cases of acute lymphoid leukemia, 33% in cases of chronic lymphoid leukemia, and 13% in cases of chronic myeloid leukemia. Vision-threatening complications such as subhyaloid hemorrhage involving the posterior pole (20%) and vitreous hemorrhage (10%) were seen exclusively in patients with acute leukemias. Multivariable logistic regression after adjusting for the type of leukemia, patient age, and white blood cell and platelet counts showed that the hemoglobin level was the only factor predictive of developing subhyaloid hemorrhage (every 1-g/L increment increase in hemoglobin level led to a 30% reduction in the likelihood of developing subhyaloid hemorrhage; 95% confidence interval 0.5-0.9; P = 0.02). The probability of developing subhyaloid hemorrhage was reduced by >50% when hemoglobin level improved from 5 to 7 g/L and when platelet count improved from 10 000 to 50 000 cells/mm³ for both types of acute leukemia. There was no association between white blood cell counts and ophthalmic manifestations.

CONCLUSION

Leukemic ophthalmopathy is more common in acute and myeloid cases and less common in chronic and lymphoid subtypes. It is predominantly due to secondary rheological changes. Blood transfusion should be considered when hemoglobin level and platelet count decrease below 7 g/L and 50 000 cells/mm³, respectively, to prevent vision-threatening complications. Patients with acute leukemias should undergo ophthalmic screening at baseline and then periodically to prevent visual morbidity.

Retinal haemorrhages: a clue to the underlying leukaemia

A 40-year-old man presented with a sudden onset of diminution of vision in his left eye for 2 days. Anterior segment of both eyes was within normal limits. Right eye retinal evaluation was normal. However, the left eye retinal evaluation showed isolated subinternal limiting membrane haemorrhage at the fovea along with a white-centred haemorrhage above the fovea. There was no antecedent history of trauma or valsalva. He was normotensive and his glycaemic status was also normal. His blood investigations along with peripheral smear were done, which helped to clinch the diagnosis of an underlying chronic myeloid leukaemia.

Ocular manifestations in leukemia and myeloproliferative disorders and their association with hematological parameters

Objectives:

To study the ocular manifestations in patients diagnosed with leukemia or myeloproliferative disorders and to derive an association between the ocular manifestations and hematological parameters of the patients.

Materials and Methods:

This observational and descriptive study was conducted in a Tertiary Care Center of Dehradun, North India over a period of 1 year. All the diagnosed cases of leukemia and myeloproliferative diseases attending the Oncology Department were included. Patients underwent a detailed ocular examination. The hematological parameters were also recorded including hemoglobin (Hb), total leukocyte count (TLC), and platelet count.

Results:

The study included 102 patients out of which, there were 66 males (64.7%), and 36 were females (35.3%) with an age range of 5–80 years. A total of forty patients showed ocular manifestations (39.3%). Extraocular manifestations were seen in 10.8% patients while intraocular manifestations were noted in 45.1% patients of acute leukemia and 7.7% patients of chronic leukemia. These ocular manifestations showed a significant association with low Hb (P = 0.000), raised TLC (P = 0.004), and low platelet count (P = 0.000). The most common ocular manifestation was intraretinal hemorrhages followed by roth spots. Among acute myeloid leukemia patients (23.5%), the presence of intraretinal hemorrhages was significantly associated with low Hb (Mann–Whitney U-test = 25.000, P = 0.007). The patients of acute lymphoblastic leukemia (25.4%) showed significant association between intraretinal hemorrhages and low platelet count (Mann–Whitney U-test = 44.000, P = 0.046) and roth spots with low Hb (Mann–Whitney U-test = 11.000, P = 0.000). Ocular manifestations were more commonly seen in acute leukemias as compared to chronic leukemias.

Conclusion:

Ocular examination is recommended in all leukemic patients as ocular manifestations may go unnoticed, most patients being asymptomatic and could be an early sign of worsening of disease.

Anterior chamber exudation in chronic myeloid leukaemia

Anterior chamber leukaemic hypopyon is a rare occurrence in chronic myeloid leukaemia. We discuss two cases marked by rapid exudation inside the anterior chamber, which were subsequently diagnosed as chronic myeloid leukaemia. The hypopyon in both the cases resolved on induction of chemotherapy.

Extramedullary Relapse of Acute Myelogenous Leukemia Presenting as a Large Serous Retinal Detachment

BACKGROUND/AIMS

To describe the rare presentation of a large, unilateral, serous retinal detachment as an extramedullary manifestation of acute myelogenous leukemia (AML) recurrence without bone marrow or central nervous system involvement after more than 1 year of follow-up.

METHODS

Case report.

RESULTS

A teenage patient with AML, previously treated with multiple courses of systemic chemotherapy, radiation, and bone marrow transplant, presented with acute vision loss. Ophthalmic workup revealed a large, unilateral, bullous, serous retinal detachment. Ultimately, he underwent subretinal fluid biopsy, which was found to be positive for leukemic blast cells. Cytologic markers matched his initial bone marrow biopsy, and therefore were diagnostic of extramedullary AML relapse.

CONCLUSIONS

Leukemia can cause various ophthalmic manifestations. Autopsy studies suggest that choroidal infiltration is relatively common, but clinical progression to serous retinal detachment is quite uncommon. Furthermore, serous retinal detachment is generally shallow, posterior, and much more often reported in acute lymphocytic leukemia. The ophthalmologist plays a critical role in identifying leukemic ocular involvement. This case demonstrates the potential for ocular biopsy to secure the diagnosis of extramedullary relapse in order to initiate prompt treatment and systemic workup.