Submit Your Article CMED MEACR meeting
Home Print this page Email this page Users Online: 574
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
LETTER TO THE EDITOR
Year : 2012  |  Volume : 1  |  Issue : 4  |  Page : 262-263

Infiltrative optic neuropathy as an initial presentation of acute lymphoblastic leukemia


1 Department of Radiotherapy, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India
2 Department of Radiotherapy, SSKM Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication21-Jan-2013

Correspondence Address:
Tamojit Chaudhuri
Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow-226 014
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0513.106263

Rights and Permissions

How to cite this article:
Chaudhuri T, Roy S, Roy P. Infiltrative optic neuropathy as an initial presentation of acute lymphoblastic leukemia. Clin Cancer Investig J 2012;1:262-3

How to cite this URL:
Chaudhuri T, Roy S, Roy P. Infiltrative optic neuropathy as an initial presentation of acute lymphoblastic leukemia. Clin Cancer Investig J [serial online] 2012 [cited 2019 Oct 13];1:262-3. Available from: http://www.ccij-online.org/text.asp?2012/1/4/262/106263

Sir,

We report a 20-year-old male with infiltrative optic neuropathy of the left eye, leading to irreversible blindness as an initial presentation of high risk T-cell acute lymphoblastic leukemia (ALL). Visual symptoms due to optic nerve infiltration by leukemic cells are rarely found in ALL. Blindness due to infiltrative optic neuropathy as the first presentation of ALL is extremely rare.

A 20-year old male presented with complaints of progressive decrease of vision in his left eye for last one month, leading to sudden blindness. There was no history of pain, redness, or watering. On examination, perception of light was absent in the left eye. Fundus examination of the left eye revealed temporal pallor of the optic disc with blurred margins [Figure 1]. Examination of the right eye revealed no abnormality. B-scan ultrasonography revealed left optic nerve thickening. Magnetic resonance imaging (MRI) of the head and face showed thickening of the extraocular portion of left optic nerve without any intracranial abnormality [Figure 2]. Peripheral blood picture and bone marrow examination revealed features consistent with ALL. Cerebrospinal fluid cytology revealed presence of leukemic blasts. Immunophenotyping showed CD3 and CD5 positivity. In view of positivity for chromosomal translocation t(4;11) (q21;q23), he was diagnosed as a case of high risk T- cell ALL with infiltrative optic neuropathy of the left eye due to leukemic cell infiltration. For optic neuropathy, the patient was recommended topical and systemic steroids. He was given chemotherapy as per ALL-BFM 95 protocol. At first remission, he received 18 Gray/10 fractions therapeutic cranial irradiation, followed by 6 Gray/3 fractions boost to left optic nerve with 3-Dimentional conformal radiotherapy (3D-CRT) technique. There was no improvement of the left eye vision, even after 3 months of treatment completion.
Figure 1: Fundoscopic image of the left eye showing temporal pallor of the optic disc with blurred margins

Click here to view
Figure 2: Magnetic resonance imaging (T1 sequence) showing thickening of the extraocular portion of left optic nerve without any intracranial abnormality

Click here to view


All can rarely present in adults as visual changes due to leukemic optic nerve infiltration. [1] In a prospective study of ocular manifestations in childhood acute leukaemia, Reddy et al.[2] found that although 3.6% of children presented with eye symptoms, on examination ocular changes were found in 17% cases, and these were 2.5 times more common in lymphoblastic leukemia than myeloid leukemia. In view of the high prevalence of asymptomatic ocular lesions in childhood acute leukaemia, the authors concluded that routine ophthalmic examination should be included as a part of evaluation at the time of diagnosis. [2]

The ocular lesions reported in All, were proptosis, intraretinal haemorrhage, white centered haemorrhage, cotton wool spots, macular haemorrhage, subhyaloid haemorrhage, vitreous haemorrhage, papilloedema, cortical blindness, sixth nerve palsy, exudative retinal detachment with choroidal infiltration; [1],[2] peripheral ulcerative keratitis with bilateral optic nerve involvement; [3] central retinal artery occlusion associated with leukemic optic neuropathy. [4]

Ocular involvement in lymphoproliferative disorders other than All have also been reported e.g. in myeloid leukemia [2] and Hodgkin's disease. [5]

Acute-onset optic neuropathy in a patient with a history of a lymphoproliferative disorder may be the only sign of a re-emergence of the malignancy. [5],[6]

In some reports, there was dramatic improvement of vision with urgent radiotherapy and high- dose systemic corticosteroids, in leukemic or lymphomatous optic nerve infiltration. [1],[5] But, no visual gain could be achieved in some reports, [3] like in our patient, and the probable causes might be late presentation with irreversible optic nerve damage and delay in radiotherapy.

 
  References Top

1.Mayo GL, Carter JE, McKinnon SJ. Bilateral optic disk edema and blindness as initial presentation of acute lymphocytic leukemia. Am J Ophthalmol 2002;134:141-2.  Back to cited text no. 1
[PUBMED]    
2.Reddy SC, Menon BS. A prospective study of ocular manifestations in childhood acute leukaemia. Acta Ophthalmol Sc and 1998;76:700-3.  Back to cited text no. 2
[PUBMED]    
3.Chawla B, Agarwal P, Tandon R, Titiyal JS. Peripheral ulcerative keratitis with bilateral optic nerve involvement as an initial presentation of acute lymphocytic leukemia in an adult. Int Ophthalmol 2009;29:53-5.  Back to cited text no. 3
[PUBMED]    
4.Iwami T, Nishida Y, Mukaisho M, Kani K, Narita T, Taga T. Central retinal artery occlusion associated with leukemic optic neuropathy. J Pediatr Ophthalmol Strabismus 2003;40:54-6.  Back to cited text no. 4
[PUBMED]    
5.Siatkowski RM, Lam BL, Schatz NJ, Glaser JS, Byrne SF, Hughes JR. Optic neuropathy in Hodgkin's disease. Am J Ophthalmol 1992;114:625-9.  Back to cited text no. 5
[PUBMED]    
6.Schwartz CL, Miller NR, Wharam MD, Leventhal BG. The optic nerve as the site of initial relapse in childhood acute lymphoblastic leukemia. Cancer 1989;63:1616-20.  Back to cited text no. 6
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
References
Article Figures

 Article Access Statistics
    Viewed1747    
    Printed35    
    Emailed0    
    PDF Downloaded138    
    Comments [Add]    

Recommend this journal