Relapse of Acute Lymphoblastic Leukemia presenting as Optic Disc Edema at TOSCON 2024
At the 9th Annual State Ophthalmological Conference (TOSCON) in 2024, Dr. S. Arthi presented a case of a 21-year-old male with a history of Acute Lymphoblastic Leukemia (ALL) who experienced a relapse presenting as optic disc edema. Despite chemotherapy and being under remission, the patient developed vision issues along with headaches. Ocular manifestations of leukemia are rare but significant, emphasizing the need for vigilant monitoring in ALL patients.
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Poster Manoj Manoj Mathur Mathur E E- -Poster [RELAPSE OF ALL PRESENTING AS OPTIC DISC EDEMA] [RELAPSE OF ALL PRESENTING AS OPTIC DISC EDEMA] [DR S ARTHI] [DR S ARTHI] Towers, Hyderabad Hyderabad 9 9th thAnnual Annual State 12th thto to 14 14th thJuly, July, 2024 State Ophthalmological Ophthalmological Conference Conference TOSCON TOSCON 2024 2024 12 2024 at at Katriya Katriya Hotel Hotel & & Towers, RELAPSE OF ACUTE LYMPHOBLASTIC LUEKEMIA PRESENTING AS OPTIC DISC EDEMA Author: Dr S Arthi (Junior Resident yr-2, OMC) Co-Author: Dr Anand Kumar (Asso Professor Department Of Ophthalmology, Sarojini Devi Eye Hospital) Dr Rajalingam(Professor and Medical Superintendent Department Of Ophthalmology, Sarojini Devi Eye Hospital)
Poster Manoj Manoj Mathur Mathur E E- -Poster Towers, Hyderabad Hyderabad 9 9th thAnnual Annual State 12th thto to 14 14th thJuly, July, 2024 State Ophthalmological Ophthalmological Conference Conference TOSCON TOSCON 2024 INTRODUCTION 2024 12 2024 at at Katriya Katriya Hotel Hotel & & Towers, Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy.Despite many advances in therapy, ALL remains an important cause of morbidity and mortality in children and adults. About 15% 20% of ALL patients experience a disease relapse. Relapses occur in bone marrow in 50% 60% of cases. Other sites include central nervous system (CNS) in approximately 20%, isolated testicular relapse in approximately 5% and a combination of marrow and extramedullary disease in the remainder. Relapse of childhood ALL involving the eye is a rare event and represents only 2.2% of ALL relapses. Although retina is the most common site of ocular manifestations of leukemia, all parts of the eye can be involved either prior to systemic diagnosis or during the disease course. Ref- wiki.clinicalflow.com. (n.d.). Acute B Lymphoblastic Leukemia (B-ALL) | Flow Cytometry
Poster Manoj Manoj Mathur Mathur E E- -Poster Towers, Hyderabad Hyderabad 9 9th thAnnual Annual State 12th thto to 14 14th thJuly, July, 2024 State Ophthalmological Ophthalmological Conference Conference TOSCON MATERIALS AND METHODS TOSCON 2024 2024 12 2024 at at Katriya Katriya Hotel Hotel & & Towers, HISTORY A 21-year-old male patient presented with complaints of diminution of vision in[RE] since 1 month sudden onset, painless and progressive associated with on and off headache. Patient is K/C/O Acute lymphoblastic leukemia [ALL] since 3 yrs. Completed six cycles of chemotherapy, now under Remission. ON EXAMINATION: RIGHT EYE LEFT EYE PL+ ve 6/6 VISION PUPIL RAPD+ Normal size reacting to light Significant Disc Edema with tortuous retinal vessels and hemorrhages FUNDUS Fundus within Normal limits RE Significant Disc Edema with tortuous retinal vessels and hemorrhages
Poster Manoj Manoj Mathur Mathur E E- -Poster Towers, Hyderabad Hyderabad 9 9th thAnnual Annual State 12th thto to 14 14th thJuly, July, 2024 State Ophthalmological Ophthalmological Conference Conference TOSCON TOSCON 2024 2024 12 2024 at at Katriya Katriya Hotel Hotel & & Towers, RE B-SCAN INVESTIGATION B-Scan:[RE]Well defined Hyperechoic lesion in subretinal space infront of the optic nerve shadow with moderate high spikes on A-scan overlay CT orbits: [RE] Hyperdense changes measuring 13*4mm in posterior vitreous suggesting inflammatory or granulomatous change with thickened optic nerve Suspecting Relapse of ALL patient referred to oncologist where: Blood Picture showed leukocytosis with 65% lymphocytes Bone marrow aspiration showed 45% blasts HB 15 GM% RBC 4.5cells/cumm WBC 6,900cells/cumm Pt was confirmed to have recurrence of Acute lymphoblastic leukemia presenting as Optic Nerve Infiltration and was planned for restarting chemotherapy but was deferred i/v/o SEPSIS PLT 0.58lakhs/cumm LYMPHOCYTES 65% Bone marrow asp 45% lymphoblasts
Poster Manoj Manoj Mathur Mathur E E- -Poster Towers, Hyderabad Hyderabad 9 9th thAnnual Annual State AFTER AFTER ONE 12th thto to 14 IN BE 14th thJuly, July, 2024 BE State Ophthalmological Ophthalmological Conference ONE MONTH MONTH PATIENT Conference TOSCON PATIENT CAME CAME WITH TOSCON 2024 WITH DOV 2024 12 DOV IN 2024 at at Katriya Katriya Hotel Hotel & & Towers, HB 15GM% RE B scan - Hyperechoic lesion in subretinal space in front of the optic nerve shadow with disc excavation RE LE RBC 4.5cells/cumm VISION PL+ve CF-CF WBC 16,900cells/cumm BE APD PUPIL PLT 0.58lakhs/cumm FUNDUS BE DISC EDEMA LYMPHOCYTES 90% Bone marrow asp 70% lymphoblasts Relapse of ALL presenting as B/L optic nerve infiltration established and Patient was referred back to oncologist to restart chemotherapy immediately RE Fundus showing significant disc edema with tortuous vessels and haemorrhages LE Fundus showing Disc Edema with tortuous vessels
Manoj Manoj Mathur Mathur E E- - Poster Poster Towers, Hyderabad Hyderabad 9 9th thAnnual Annual State 12th thto to 14 14th thJuly, July, 2024 State Ophthalmological Ophthalmological Conference Conference TOSCON TOSCON 2024 DISCUSSION 2024 12 2024 at at Katriya Katriya Hotel Hotel & & Towers, Optic neuropathy in leukemia can be due to infiltration, infections, compression, vasculitis, radiotherapy or chemotherapy induced complications. A lumbar puncture must be performed to aid in this differentiation. In leukemic infiltration of the optic nerve, fundus examination usually reveals optic disc edema and diffuse hemorrhages, while is normal in other patients. A review by Myers et al. found that malignant cells are identified in the CSF in a majority of patients with leukemic infiltration of the optic nerve. Vitreous biopsy may be helpful in accurate diagnosis when CSF analysis is negative for leukemic cells. The prognosis for patients with ocular involvement is generally poor. Routine ophthalmologic screening may antedate the diagnosis of relapse and positively impact on prognosis. CONCLUSION Although leukemic infiltration of optic Nerve is rare event but is an emergency as early Diagnosis and Treatment of ALL Relapse is critical for visual recovery and survival. Therefore, any ocular complaints in patients with past history of ALL should be promptly evaluated Ref- Dini G, Capolsini I, et al. Acute lymphoblastic leukemia relapse presenting with optic nerve infiltration. SAGE Open Med Case Rep. 2023 May 22
