ocular manifestation of leukemia patients.the information is significant and can help in the screening , diagnosis and early management.

1. Topic :ophthalmic manifestation
in leukemia
By Cynthia Oloo
Bsc.comprehessive Ophthalmology and cataract surgery
Jomo Kenyatta University of Agriculture and Technology/Sabatia Eye Hospital

3. Ocular manifestation
• Leukemia is a group of malignant neoplasms derived from the
hematopoietic stem cells as a results of abnormal proliferations of
blood cells in the bone marrow
• Liebreich first described leukemic retinopathy in1863
• Classified into acute or chronic or lymphoid or myeloid type
• ALL is most common ocular manifestation occurs in 90% of cases
• Ophthalmic classification is categorized into 2 major
 primary or direct leukemic infiltration
Secondary or indirect leukemic infiltration

4. Cont ,
DIRECT
• Can have 3 patterns
1. Infiltration of the orbit mimicking orbital inflammation diseases
2. Direct infiltration of the : Ant segment, vitreous, choroid, retina
mimicking uveitis, choroiditis and retinitis
3. Infiltration of the optic nerve presenting with or without another
CN III, IV,VI

5. Orbit and eyelids
Primary –it more common in ALL
• Orbit infiltration – exophthalmos, diplopia
• Eyelids –edema , inflammation, chemosis, pain
Secondary –orbit can show affectation after remission
• Lacrimal glands are affected causing tears dysfunction
• Preseptal cellulitis , acute dacrocystitis in ISS pts

6. conjunctiva
Primary- hyperemia , edematization of lower subpalpebral conjunctiva
• Infiltrates can be seen around vessels
• In the form of a conjunctival mass
Secondary- hyperviscosity can produce vascular anomalies
• 4 stages of severity- hyperemia, chemosis, pseudomembranous with
complete loss of conjunctival epithelium , compromise of the corneal
epithelium(cook and bartley et al 1997)
• Severe DES due to Meibomian dysfunction
• Can lead to ectropion, cicatricial lagophthalm
Palpebral linchenification

7. ectropion LL

8. Sclera
Primary – scleral infiltration is common in ALL, can stimulate scleritis
Episcleritis is associated by Adult-T cell lymphocytes
• Around the episcleral vessel
• It usually asymptomatic
• Can be autopsy finding(Sharma et al, 2004)
Secondary- Opportunistic infectious scleritis in ISS pts

9. Cornea
Primary – is avascular structure
• It is hardly affected by direct
• Ring-shaped, corneal ulcers, subepithelial limbal infiltrates, peripheral
ulcers (Tayor et al, 1997)
Secondary- Citarabine that corneal toxicity
• Interefering with epithelium’s synthesis of DNA
• Keratoconjunctivitis sicca is most common manifestation
• Acute calcium keratopathy, corneal thining, keratitis,
ulcers(herpetic/fungal, corneal melting, perforation

10. Anterior chamber and iridocorneal angle
Primary – anterior uveitis, pseudohypopyon, spontaneous hyphema
• Infiltration of iris is not common
• It occurs associated with involvement of choroid and ciliary body
• Characterized by change of iris color ,pseudohypopyon ,grey /yellow
• Hpopyon estimated 2.5 to 18% relapsed cases
• IOPs may be high to show signs of acute glaucoma

11. Cont,
Secondary-hypopyon uveitis secondary due to anaemia
• Ischaemia of the anterior segment may cause corneal edema,
• Conjunctival chemosis, visual loss, anterior uveitis,high IOPs, eye
pain
Lens
• Subcapsular cataract
• Consequences of use of steroid,
• Chemotherapy, radiotherapy
• Ischaemic causes due to anaemia

12. Vitreous
• Vitreous opacities and infiltration of leukemic cells in the vitreous
body

13. Choroid
Primary-is most commonly affected ocular tissue
• Involvement is not clinically apparent
• Choroidal and orbital leukemic infiltration mimic advanced RB
• Diffuse or perivascular involvement
• If affected , overlying retina shows alterations such as photoreceptor
Damage, RPE atrophy,
SRD , usually bilateral, affecting posterior pole

14. Cont,
Secondary-much less common
• Retinochoroidal infarction detected during RX of ALL

15. Retina
Primary- very commonly
• 70% of pts with leukemia shows fundus changes(Alemayesh et al, 1996)
• Early –venous dilatation , tortuosity,
• Vascular sheathing, superficial and intraretinal
Hemorrhages

16. Cont,
• Cotton wool spots –due to ischaemic( leukemic retinopathy)
• CRAO in pt with hyperviscosity

17. Cont,
• Retinal hemorrhages –mainly at the posterior pole
• Inner layers with focal destruction
• May be dot or flame shaped with a white component in the center
• White component contain; leukemic cells, debris , platelet -fibrin
aggregates or septic emboli
Secondary-OI involves retina during period of neutropenia
• Susceptible to CMV, candida aspergillus(common)
• Protozoa, bacteria

18. Cont,
• Other viruses such as herpes, varicella, munps
• May cause necrotizing retinitis

19. Optic nerve
Primary- O.N usually involved in CNS
• It can happen in upto 13-18% of cases
• Symptoms depends on raised ICP and affectation of CN
• Ocular symptoms –blurred vision, loss of VA or diplopia(CN
III,IV,VI)
• Affectation of ON is asymptomatic
• Papilloedema can be found ;Due to
1. Direct infiltration by leukemic cells
2. Increased Intraocular pressure
3. Swelling due to retrolaminar leukemic invasion

20. Cont,
• ON can singly be affected without papilloedema
• Affectation of ON occurs during evolution of ALL
Secondary – Toxicity of chemo, radio, antibiotics
• Ischaemia after anaemia or hyperviscosity

21. Treatment
Intravitreal injections
1. Dexamethasone
2. Anti –VEGFs
3. Methotrexate (MTX)-400mg/0.1ml twice weekly in the first month,
Once weekly in 2 months, then once monthly

22. conclusion
• Ophthalmic manifestation in pts suffering ALL are very common
• Ocular involvement can be caused by directly infiltration by leukemic
cells
• Secondary to anaemia, thrombocytopenia, leukopenia, hyperviscosity
and Ois in ISS pts
• RX is difficult because the effect of chemo in the eye is very limited
• Radio is frequently used for RX
• RX with methotrexate has shown improvement according to
retrospective done at ocular oncology service at the Goldscleger Eye
institute

23. Referrence
• In -tech ophthalmic manifestation of lymphoblastic leukemia
• Scientific report (2020) on ocular manifestation of leukemia and
results of treatment with intravitreal methotreaxate