Statistics from Altmetric.com
Editor,—Various ocular complications in leukaemia are due to direct invasion by leukaemic cells or haematological abnormalities associated with leukaemia—for example, anaemia, thrombocytopenia, and hyperviscosity states.1 2 These complications usually occur when the disease is clinically and haematologically active but rarely during complete remission. Moreover, serous retinal detachment is a less common complication, while dilated and tortuous vessels, vascular sheathing, white centred retinal haemorrhages, intraretinal haemorrhages, and cotton wool spots are often seen in the fundus. We describe an uncommon case of a young boy who showed a serous retinal detachment during the first complete remission of his acute lymphocytic leukaemia (ALL).
A 17 year old boy presented with gradually blurring vision and metamorphopsia in his right eye. ALL had been diagnosed and treated with chemotherapy 9 months earlier. His disease was in complete remission at the time of presentation. Corrected visual acuity was 20/250 in the right eye and 20/15 in the left eye. Fundus examination of the right eye showed a serous retinal detachment involving the fovea in the posterior pole (Fig 1A). There were no retinal holes. The left eye was normal. Fluorescein angiography showed numerous hyperfluorescent dots beneath the retina and diffuse subretinal accumulation of fluorescein with time (Fig 1B). B-scan ultrasonography demonstrated diffuse leukaemic infiltration of the choroid beneath the retinal detachment. Simultaneous A-scan indicated thickening of the choroid to be 2.5 mm (Fig 2). The white blood cell count was 4.8×109/l with a normal differential but bone marrow aspiration showed 91.6% lymphoblasts. The patient received systemic chemotherapy immediately. Three weeks later, visual acuity in the right eye improved to 20/20 and the serous retinal detachment decreased markedly.
Main fundus manifestations of leukaemia are round or flame-shaped haemorrhages with a white component, intraretinal haemorrhages, and cotton wool spots, comprising what is called “leukaemic retinopathy”. These retinal findings are observed commonly but serous retinal detachment is unusual in leukaemia1 3 4 and even much less common during complete remission.5 The serous retinal detachment observed in leukaemia is reported to be shallow in the posterior poles. Fluorescein angiography shows multifocal hyperfluorescence beneath the detachment in the early phase and diffuse subretinal accumulation of fluorescein in the late phase, which was also observed in our case. This angiographic finding is probably due to retinal pigment epithelial disturbances secondary to circulatory or metabolic changes in the underlying choriocapillaris. Stewartet al 4 postulated that leukaemic infiltration of the choroid caused decreased blood flow in the choriocapillaris, resulting in ischaemia to the overlying retinal pigment epithelium and disruption of the intercellular tight junctions.
If leukaemic choroidal involvement is evident clinically, it usually presents as a serous retinal detachment.1 However, none of those reporting serous retinal detachments in leukaemia could demonstrate leukaemic infiltration of the choroid even with ultrasonography.3 4 In contrast, Abramsonet al 6 reported that leukaemic involvement of the choroid could easily and reliably be detected with contact ultrasonography. Although we could also detect leukaemic infiltration of the posterior choroid with ultrasonography in our case, we could not have found it if it had been much thinner. It may be difficult to detect thin diffuse choroidal infiltration even with ultrasonography, just as it is difficult to diagnose a flat melanoma or diffuse intraocular pseudotumour.1
Intraocular manifestations of leukaemia usually are not treated directly. First of all, systemic chemotherapy is attempted. When definite leukaemic infiltrates fail to respond promptly to systemic chemotherapy, ocular radiation is usually recommended.2 In our case, only systemic chemotherapy was administered but the serous retinal detachment was resolved promptly and the visual acuity in the affected eye improved to 20/20. This case suggested that systemic chemotherapy alone could preserve visual acuity if performed early.
As the rate of remission induction in leukaemic patients increases, ophthalmic examination is becoming more important during remission. Serous retinal detachment caused by leukaemia clinically may mimic a simple central serous chorioretinopathy. Ophthalmologists should bear this in mind in leukaemic patients even in apparent remission.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.