Home | About IJMPO | Editorial board | Search | Ahead of print | Current Issue | Archives | Instructions | Subscribe | Advertise | Contact us |  Login 
Indian Journal of Medical and Paediatric Oncology
Search Article 
  
Advanced search 
 

 Table of Contents      
LETTER TO EDITOR
Year : 2013  |  Volume : 34  |  Issue : 4  |  Page : 335-336  

Ischaemic optic neuropathy induced sudden blindness as an initial presentation of acute lymphoblastic leukemia


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

Date of Web Publication18-Jan-2014

Correspondence Address:
Tamojit Chaudhuri
Department of Radiotherapy, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-5851.125266

Rights and Permissions

How to cite this article:
Chaudhuri T, Roy S, Roy P. Ischaemic optic neuropathy induced sudden blindness as an initial presentation of acute lymphoblastic leukemia. Indian J Med Paediatr Oncol 2013;34:335-6

How to cite this URL:
Chaudhuri T, Roy S, Roy P. Ischaemic optic neuropathy induced sudden blindness as an initial presentation of acute lymphoblastic leukemia. Indian J Med Paediatr Oncol [serial online] 2013 [cited 2019 Nov 14];34:335-6. Available from: http://www.ijmpo.org/text.asp?2013/34/4/335/125266

Sir,

We report a 18-year-old male with ischaemic 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 ischaemic optic neuropathy as the first presentation of ALL is extremely rare.

A 18-year-old male presented with progressive decrease of vision in his left eye for last 3 weeks, 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. Electrophysiological tests showed markedly reduced visual evoked responses. Magnetic resonance imaging of head and face showed thickening of the extraocular portion of the left optic nerve along with great edema without any intracranial abnormality [Figure 2]. Peripheral blood picture and bone marrow examination revealed features consistent with acute lymphoblastic leukemia (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 ischaemic optic neuropathy of the left eye due to leukemic infiltration and edematous compression. 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 three-dimensional 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 the left optic nerve along with great edema without any intracranial abnormality

Click here to view


Acute lymphoblastic leukemia (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 leukemia, 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 leukemia, 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 hemorrhages, white centered hemorrhages, cotton wool spots, macular hemorrhage, subhyaloid hemorrhage, vitreous hemorrhage, papilledema, 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 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] However, 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 Scand 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
    
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
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 A case of leukemic retinopathy mimicking common ischemic retinopathies
Agnes Awuah,Kofi Asiedu,Madison Adanusa,Michael Ntodie,Ebo Acquah,Samuel Kyei
Clinical Case Reports. 2016; 4(2): 133
[Pubmed] | [DOI]



 

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
    Viewed976    
    Printed14    
    Emailed0    
    PDF Downloaded171    
    Comments [Add]    
    Cited by others 1    

Recommend this journal