Acute Lymphoblastic Leukemia Presenting as Unilateral Leopard Spots Exudative Retinopathy

By Diva Kant Misra, MBBS, DO, DNB, MNAMS, FVRS; Dipankar Das, MBBS, MS; Ronel Soibam, MBBS, MS; Awaneesh Upadhyay, MBBS, DNB, FVRS; and Harsha Bhattacharjee, MBBS, MS, FRCP, FRCS
 

An 11-year-old girl presented with dimness of vision in the left eye (OS) for 1 week. Her medical history included B-cell acute lymphocytic leukemia (B-ALL) diagnosed 2 years earlier. Immunohistochemistry had identified the tumor as common-ALL associated antigen positive, also called CALLA+. The patient underwent chemotherapy and cranial radiotherapy (CRT) at that time. On presentation at our center, the patient had no headache, fever, or nausea, and she was on monthly maintenance chemotherapy.

On examination, her VA was 20/20, N6 in the right eye and hand motion+, N36 OS. Extraocular movement was normal, the anterior chamber was unremarkable, and IOP was normal. Fundus examination revealed leopard spots exudative retinal detachment (ERD) with florid vessels prominent at the optic disc OS (top Image). B-scan ultrasound OS revealed multiple ERDs with an increase in choroidal thickness of 2 mm and low reflective echoes in the vitreous cavity. OCT OS showed gross thickening of the retinochoroidal complex. An MRI scan of the brain and orbit revealed an intraocular leukemic deposit OS (bottom left). Brain MRI and peripheral blood smear were normal.

The patient was advised to consult the radiation oncologist for possible further CRT. Her parents were also advised to consult the treating oncologist with the new metastatic findings OS.

At 6-week follow-up, the patient’s VA had improved to 20/20 OS, fundus findings OS were improved (bottom right), and the disease was in remission. Mild phthisical change was noted OS.

Ophthalmic manifestations of ALL can vary.1-4 Findings in the posterior segment in patients with ALL include retinal hemorrhages with Roth spots, vascular sheathing, cotton wool spots, optic disc edema, and ERD.2-4

1. Ohkoshi K, Tsiaras WG. Prognostic importance of ophthalmic manifestations in childhood leukaemia. Br J Ophthalmol. 1992;76:651-655.

2. Primack JD, Smith ME, Tychsen L. Retinal detachment in a child as the first sign of leukemic relapse: Histopathology, MRI findings, treatment, and tumor-free follow up. J Pediatr Ophthalmol Strabismus. 1995;32:253-256.

3. Rosenthal AR. Ocular manifestations of leukemia: a review. Ophthalmology. 1983;90:899-905.

4. Sharma T, Grewal J, Gupta S, Murray PI. Ophthalmic manifestations of acute leukaemias: the ophthalmologist’s role. Eye (Lond). 2004;18:663-672.

Section Editor Manish Nagpal, MS, DO, FRCS(Edin)
• Senior Consultant, Retina and Vitreous Services, Retina Foundation, Ahmedabad, India
drmanishnagpal@yahoo.com

Diva Kant Misra, MBBS, DO, DNB, MNAMS, FVRS
• Senior Fellow, Vitreo-Retina Services, Sri Sankaradeva Nethralaya, Guwahati, India
divakant@gmail.com
• Financial disclosure: None

Dipankar Das, MBBS, MS
• Senior Consultant, Department of Ocular Pathology, Uveitis, and Neuro-Ophthalmology Services, Sir Sankaradeva Nethralaya, Guwahati, India
dr_dasdipankar@yahoo.com
• Financial disclosure: None

Ronel Soibam, MBBS, MS
• Senior Consultant, Vitreo-Retina Services, Sir Sankaradeva Nethralaya, Guwahati, India
ronelsoibam@yahoo.co.in
• Financial disclosure: None

Awaneesh Upadhyay, MBBS, DNB, FVRS
• Junior Consultant, Vitreo-Retina Services. Sir Sankaradeva Nethralaya, Guwahati, India
drawaneesh@gmail.com
• Financial disclosure: None

Harsha Bhattacharjee, MBBS, MS, FRCP, FRCS
• Medical Director, Sir Sankaradeva Nethralaya, Guwahati, India
drharshabhattacharjee@gmail.com
• Financial disclosure: None

To share an image, contact Dr. Nagpal at drmanishnagpal@yahoo.com.
Note: Images should be 400 dpi or higher and at least 10 inches wide.

 

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Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.