Author: Ahmed Al-Janabi (United Kingdom)
Co-authors: Ahmed AL-Janabi, Kevin Gallagher
Purpose
We describe a case of a patient with chronic myeloid leukaemia presenting with rapidly worsening vision and bilateral, symmetrical cystoid macular oedema. He later developed bilateral proliferative retinopathy.
Setting/Venue
The patient is a 54-year-old man with type 1 DM (diagnosed in 1992) and hypercholesterolemia. He presented with a 3-month history of bilateral symmetrical blurring of vision. Visual acuity was 6/24 right eye and 6/12 left eye. Fundoscopy showed multiple creamy-white cotton-wool spots (CWS) at the posterior pole, no exudation and few retinal haemorrhages. An OCT scan showed significant cystoid macular oedema. 2 weeks later, his acuity had worsened to 6/60 in each eye with concurrent worsening of his macular oedema.
Methods
He was initially treated as diabetic macular with a course of bilateral aflibercept injections. On later review however, it was felt that the clinical features were not typical of diabetic macular oedema, namely multiple CWS within the macula, the absence of any exudates, bilateral symmetrical oedema with the typical “vaulted ceiling” appearance of cystoid macular oedema and the rapidity with which his acuity was worsening. Six months after his initial presentation, he developed bilateral vitreous and subhyaloid haemorrhage with optic disc new vessels (NVD) visible in each eye. He received bilateral pan-retinal photocoagulation (PRP). His NVD regressed and the vitreous/subhyaloid haemorrhages cleared. A further six months later, he was noted to have recurrent bilateral vitreous haemorrhage with recurrent retinal new vessels visible in the left eye. Further PRP is planned.
Results
Patient received bilateral aflibercept intravitreal injections. Seven days after his first intravitreal injections, he was diagnosed with chronic myeloid leukaemia – his initial white blood cell count (WBC) was 94. He was treated with imatinib by the haematology team. One month later, his macular oedema had completely resolved in each eye with visual acuity improving to 6/6 in each eye. By this time, his WBC had reduced to 17. Intravitreal injections were paused and his macular oedema has not recurred over 12 months of follow-up.
Conlusions
Leukaemia is known to cause retinopathy. This manifests as venous tortuosity and dilatation, perivascular sheathing, retinal haemorrhages, microaneurysms, cotton wool spots and infiltration of the optic nerve and/or the retina [1] [2]. Neovascularization in leukemic patients is a rare complication which tends to occur in mid to far peripheral retina [3]. Leukaemia is presumed to induce retinal ischaemia through increased blood viscosity and clogging of blood vessels by large leukaemic cells. In patients with pre-existing diabetic retinopathy, leukaemia has been reported to rapidly accelerate retinopathy towards proliferative disease as happened in this case. Macular oedema has been reported as a complication of imatanib therapy in patients with CML but this is the first case we are aware of with bilateral cystoid macular oedema as a presenting feature of CML.
Financial Disclosure
No financial relationships
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