Bilateral optic nerve infiltration revealing acute lymphoblastic leukemia: a case report

Author: Salma El moataz billah (Morocco)

Co-authors: Soukaina Homaide, Adil Mchachi, Leila Benhmidoune, Abdelouahed Chakib, Ryad Rachid, Mohammed El Belhadji

Purpose

Acute lymphoblastic leukemia (ALL) is a neoplasm caused by the clonal proliferation of immature lymphoid cells. Ocular manifestations due to direct infiltration by neoplastic cells or secondary to abnormalities of the blood clot are rarely revealing. They are associated with a poor prognosis and require urgent management.

Setting/Venue

The patient was admitted to the ophtalmology emergency departement of 20 Aout 1953 hospital of Casablanca.

Methods

We report the case of a young patient with acute lymphoblastic leukemia revealed by bilateral infiltation of the optic nerve.

Results

A 17-year-old patient, with no premorbodities presented to the ophthalmology emergency department for bilateral rapidly progressive vision loss. On initial examination, the best corrected visual acuity was decreased to 0.7 logMar in the right eye and light perception in the left. The pupills were poorly responsive to light in both eyes with no evidence of a relative afferent pupillary defect. Slit lamp biomicroscopy was unremarkable. The intraocular pressure was recorded as 15mmHg in each eye. Dilated fundus examination revealed an optic nerve head swealing associated with tortuous and dilated retinal venules in the right eye. In the left, there was an extensive optic nerve and retinal infiltration with numerous white centered hemorrhages corresponding to Roth spots. At physical examination, a general cutaneous and mucosal pallor was noted An urgent full blood count revealed pancytopenia. The patient was referred to the hematology unit where he underwent a bone marrow biopsy establishing the diagnosis of acute lymphoblastic leukemia.

Conlusions

Ophthalmologic manifestations in acute lymphoblastic leukemia are rarely symptomatic. Unlike for the 3rd or 7th cranial pairs, the involvement of the optic nerve is rarely observed. It is secondary, as in our case, to an infiltration of the head of the optic nerve by the blast cells. There are variations in clinical presentation of optic nerve infiltration in leukaemic patients. Normal appearance of optic disc may not exclude the possibility of infiltration by malignancy. Assessment of the optic nerve function and imaging is helpful for the detection of leukaemic infiltration. The prognosis for blast infiltration of the optic nerve head is pessimistic. Overall, survival in the event of ocular localization is less than 24 months.

Financial Disclosure

No financial discolosures to declare