|Year : 2018 | Volume
| Issue : 2 | Page : 105-107
Eye - The window: An interesting case report
C Usha, B Kalai Selvi, B Pramila
Department of Ophthalmology and Government Omandurar Medical College, Chennai, Tamil Nadu, India
|Date of Web Publication||6-Aug-2018|
Dr. C Usha
Department of Ophthalmology, Government Omandurar Medical College, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Chronic myeloid leukemia (CML) is a myeloproliferative disorder. It is a form of leukemia characterized by the increased and upregulated growth of predominantly myeloid cells in the bone marrow and accumulation of these cells in the blood. We hereby reporting a 37-year-old healthy male, auto driver by occupation, presented with defective vision both eyes of insidious onset for 6 months. He is not a known diabetic, hypertensive, or any other chronic illness. Two years back he was treated for pulmonary tuberculosis with category 1 anti tubercular therapy. No other ailments in the past. We did the routine assessment and suspected CML, so asked for systemic workup. Surprisingly, the result came as CML in chronic phase. He was treated with tablet imatinib 400 mg OD.
Keywords: Chronic myeloid leukemia, chronic phase, defective vision, leukemic fundus
|How to cite this article:|
Usha C, Selvi B K, Pramila B. Eye - The window: An interesting case report. TNOA J Ophthalmic Sci Res 2018;56:105-7
| Introduction|| |
Chronic myeloid leukemia (CML) is a myeloproliferative disorder characterized by increased proliferation of granulocytic cell line, and so there will be increase in granulocyte and their immature precursor including blast cells in peripheral blood profile. Cml constitute 15% of leukemia and is more common in males of 40-60 years of age. The cause is unknown, and some with a history of exposure to ionizing radiation., The disease follows three phases — chronic phase, accelerated phase, and blast phase. About 85%—90% of patients present in chronic phase and progresses to accelerated phase and blast phase in 3—5 years.
We present here a patient who presented to the department of ophthalmology with defective vision.
| Case Report|| |
A 37-year-old healthy male [Figure 1] presented with defective vision both eyes of insidious onset for 6 months and no other systemic or other complaints., His visual acuity was 6/24 NIG in the right eye and in the left eye 6/36 NIG. Dilated fundus examination for retinoscopy revealed multiple superficial hemorrhages, exudates, retinal edema, and leukemic infiltrations in both eyes, [Figure 2]a and [Figure 2]b. Optical coherence tomography (OCT) showed increased retinal thickness, leukemic retinal infiltrates, and macular edema [Figure 3]. The patient was sent for hematological work-up. Total white blood cell count was 229,000 cells. Peripheral smear showed increased white cell count with preponderant myeloid precursors and normal platelet count, normal red blood count, moderate anisocytosis, and poikilocytosis suggestive of CML in stable phase [Figure 4]a and [Figure 4]b. Other blood parameters including blood sugar and HIV were negative. He had no previous history of any illness except for Category 1 antitubercular therapy for pulmonary tuberculosis 2 years back. Hence, the patient was referred to hematologist. His bone marrow biopsy revealed hypercellular marrow, myeloid hyperplasia, blast 7% and basophils 4% suggestive of CML in chronic phase. Ultrasonography of abdomen showed mild hepatosplenomegaly. The patient was diagnosed as CML in chronic phase by hematologist and started on tablet imatinib 400 mg OD for 2 weeks and follow-up.
|Figure 2: (a) Fundus photograph of the right eye showing perivascular retinal infiltrates, hemorrhages, and exudates. (b) Fundus photograph of the left eye showing perivascular retinal infiltrates, hemorrhages, and exudates|
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|Figure 3: Optical coherence tomography of eyes showing increased retinal thickness, retinal infiltrates, and macular edema|
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|Figure 4: (a) Peripheral blood smear showing increased myelocytes with myeloid precursors. (b) Peripheral blood smear showing increased myelocytes with myeloid precursors|
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| Discussion|| |
Most patients around 90% are diagnosed in chronic phase, and around 10% are diagnosed in accelerated or blast phase. Patients in chronic phase are diagnosed incidentally with elevated white blood cell count on a routine laboratory test. They can also present with abdominal pain due to hepatosplenomegaly or loss of appetite and weight loss., They may also present with fever and night sweats due to an elevated basal level of metabolism. It is the first cancer to be linked with genetic abnormality, translocation of chromosome. Peripheral blood of CML shows increased granulocytes of all types typically including mature myeloid cells. Bone marrow biopsy will show increased granulocyte precursors, and there will be hepatosplenomegaly. Patients of CML in chronic phase are treated with Bcr-Abl tyrosine kinase inhibitors such as imatinib, dasatinib, nilotinib, and bosutinib.
| Conclusion|| |
This patient presented to the ophthalmology department with defective vision. There was no other symptom pertaining to CML, presented here for its unusual initial presentation., Fundus examination and posterior segment OCT was suggestive of leukemic fundus, Hence, the patient was asked to undergo hematological work up to confirm our diagnosis. Blood investigation showed features of CML in chronic phase; hence, the patient was referred to hematologist, there bone marrow biopsy done and the result came as CML in chronic phase. The patient was started on tablet imatinib 400 mg OD. Although ophthalmologist has secondary role in the management of CML, a prompt recognition of ocular manifestation is crucial if appropriate therapy is to be initiated. It is important to see early fundus changes in patients who do not present with usual signs and symptoms of CML. Suspicious ocular finding has to be followed up with appropriate systemic evaluation and workup, including full blood count.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hehlmann R, Hochhaus A, Baccarani M, European LeukemiaNet. Chronic myeloid leukaemia. Lancet 2007;370:342-50.
Sokal JE, Baccarani M, Russo D, Tura S. Staging and prognosis in chronic myelogenous leukemia. Semin Hematol 1988;25:49-61.
Huang PK, Sanjay S. Visual disturbance as the first symptom of chronic myeloid leukemia. Middle East Afr J Ophthalmol 2011;18:336-8. [Full text]
Mandic BD, Potocn Jack V, Bencic G, Mandic Z, Pentz A, Hajnzic Tf. Visual loss as initial presentation in chronic myelogenous leukemia. Coll Antropol 2005;1:141-3.
Curto ML, Zingone A, Acquaviva A, Bagnulo S, Calculli L, Cristiani L, et al
. Leukemic infiltration of the eye: Results of therapy in a retrospective multicentric study. Med Pediatr Oncol 1989;17:134-9.
Allen RA, Straatsma BR. Ocular involvement in leukemia and allied disorders. Arch Ophthalmol 1961;66:490-508.
Kimura S, Ashihara E, Maekawa T. New tyrosine kinase inhibitors in the treatment of chronic myeloid leukemia. Curr Pharm Biotechnol 2006;7:371-9.
Sharma T, Grewal J, Gupta S, Murray PI. Ophthalmic manifestations of acute leukaemias: The ophthalmologist's role. Eye (Lond) 2004;18:663-72.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]