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ARTICLE
Year : 1968  |  Volume : 16  |  Issue : 2  |  Page : 89-90

Acute bilateral proptosis in acute lymphatic leukaemia


Department of Ophthalmology, Maulana Azad Medical College and Associate Irwin & G. B. Pant Hospitals, New Delhi-1, India

Date of Web Publication22-Dec-2007

Correspondence Address:
D K Sen
Department of Ophthalmology, Maulana Azad Medical College and Associate Irwin & G. B. Pant Hospitals, New Delhi-1
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Sen D K, Mohan H, Gupta D K. Acute bilateral proptosis in acute lymphatic leukaemia. Indian J Ophthalmol 1968;16:89-90

How to cite this URL:
Sen D K, Mohan H, Gupta D K. Acute bilateral proptosis in acute lymphatic leukaemia. Indian J Ophthalmol [serial online] 1968 [cited 2020 May 30];16:89-90. Available from: http://www.ijo.in/text.asp?1968/16/2/89/37502

Bilateral proptosis in acute lymp­hatic leukaemia may be due to in­volvement of the orbit by tumour cells and this was observed in 2% of cases by REESE AND GUY 5 . Here the onset of protrusion of the eye is gradual. Acute proptosis, how­ever, is due to spontaneous haemor­rhage in the orbit.

DUKE-ELDER 3 (1952) divided the etiology of heemorrhages within the orbit in three main classes: those due primarily to disease, those due to con­gestion and those due to direct trau­ma. The etiological groups of spon­taneous hemorrhages are: haemorr­hagic diathesis like haemophilia, scurvy, leukaemia etc., arterial dis­ease, vasomotor instability and toxic as is seen in typhoid fever. Of the leukaemias extraocular hemorrhages are common in the lymphatic group and they often outnumber the retinal hemorrhages, but massive intra­orbital bleeding causing sudden proptosis is rare (TREVOR-ROPER 6 . Bilaterality makes the case all the more interesting.


  Case report Top


S. R. 21 years, Hindu, male, was admitted in Irwin Hospital with the complaints of fever for about a week, severe pain in the abdomen and chest with difficulty in breathing and protrusion of both the eyes for 3 days. Right eye was the first to be affected.

Onset of protrusion of the eyes was sudden and was associated with acute irradiating pain in the orbit. There was no history of epistaxis, haematuria or haemoptysis.

General Examination

The boy was dyspnoeic, markedly pale and ill. Pulse 90/minute, regu­lar and fair in volume. Lips and nail beds were cyanotic. Gums were discoloured but not spongy. Faucial examination revealed submucosal hemorrhages. Lymph glands were enlarged in the neck, axilla and groin. Numerous petechial haemorrhages and larger ecchymoses were seen in the skin of the abdomen. Spleen and liver were palpable but not tender. B. P. 120/70 mm. of Hg.

Local Examination

The picture was more or less sym­metrical on both the sides.

The proptosis was moderate, axial and irriducible. Lids were discolour­ed, tense and swollen. Globes were completely immobile. Chemosis was very marked with lots of haemorrhages in the sub-conjunctival tissue. Cor­neae were exposed. Pupils were semidilated and sluggishly reacting to light [Figure - 1].

Ophthalmoscopic examination showed marked papilloedema on both sides. Hoemorrhages were widespread on both the sides but more in the peripapillary region. They were superficial and associated with oedema No exudates were seen. Re­tinal vessels were distended and tor­tuous.

Investigations

Haemoglobin was 45%; Red cells, 3 million per c mm. There was ani­socytosis with a few megaloblasts. Platelets were reduced in number, the count being 80,000 per c mm. White cells numbered 16,200 per c mm. Majority of them were non-gra­nular and embryonic. Lymphocytes (small and large, some with "smear­ed" nuclei) and lymphoblasts were 96 per cent; and polymorphonuclears 4 per cent. Bleeding time was prolong­ed (20 minutes). Clotting time - 12 minutes. Prothrombin time - 46 sec­onds.

On sternal puncture, bone mar­row was found to be very cellular. 94% of the cells were primitive white cells of the lymphatic series.

Having thus established the diag­nosis treatment was started very energetically with intravenous Efcorlin and cortisone orally (Prednisolone, 40 mg. daily) supported by oxygen inhalation, blood transfusion and broad spectrum antibiotics; but the treatment proved disappointing. Pa­tient's condition deteriorated quickly and death occurred on the following day.


  Comments Top


Acute leukemia has been a com­mon cause of death amongst child­ren. Of late the incidence of leu­kemia is found to be increasing (Trevor-Roper, 1967). BERNARD, BOIRON, WEIL; LEVY, SELIG­MANN AND NAJIAN 7 (1962) report­ed that they had seen at their institute a total of 497 cases of acute leukemias between 1956 - 1962. Some of these cases may report to the ophthalmologists direct for ad­vice. GOLDBACH 4 listed 33 differ­ent ocular anomalies among 242 leu­kaemias at the Johns Hopkins Hospi­tal. Majority of those anomalies are seen in the funds. Spontaneous ex­tra ocular hemorrhages though fair­ly common in any leukemia are more marked and more frequent in the lymphatic group, especially in the acute variety. Even in these cases massive intraorbital bleeding giving rise to proptosis on both the sides is very rare.

It is important to note that onset of protrusion of eye was not associated with vomiting, though DUKE­ELDER (1952) considered vomiting as an important diagnostic symptom in acute cases of orbital hemorrhage due to trigeminovagus stimulation exciting an oculo-gastric reflex. Dila­tation and sluggishness of the pupil are explained by the great pressure generated in the orbit due to the hemorrhage. Papilloedema due to local retinal affection in leukemia is known. What is difficult to say is whether any hemorrhage in the optic nerve sheath aggravated this condi­tion.

It should be noted that proptosis may be a presenting feature of acute leukemia in children. With a view to diagnosing such cases correctly and in time CROMBIE 2 suggested that in all cases of orbital proptosis, even if the peripheral blood count and film are not greatly abnormal, a bone-marrow biopsy should be per­formed and supra-vital staining tech­niques carried out so that early leu­kemia in the aleukemic phase be diagnosed.


    Figures

  [Figure - 1]



 

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