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ARTICLES
Year : 1985  |  Volume : 33  |  Issue : 2  |  Page : 135-137

Leukaemic infiltration of the optic nerves demonstration by computerized orbital tomography


Department of Neurosurgery, S.C.B. Medical College, Cuttack, India

Correspondence Address:
Madhumati Misra
Department of Neuro Surgery, S.C.B. Medical College, Cuttack -753 037
India
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Source of Support: None, Conflict of Interest: None


PMID: 3869125

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How to cite this article:
Misra M, Rath S, Rao K. Leukaemic infiltration of the optic nerves demonstration by computerized orbital tomography. Indian J Ophthalmol 1985;33:135-7

How to cite this URL:
Misra M, Rath S, Rao K. Leukaemic infiltration of the optic nerves demonstration by computerized orbital tomography. Indian J Ophthalmol [serial online] 1985 [cited 2019 Dec 7];33:135-7. Available from: http://www.ijo.in/text.asp?1985/33/2/135/30840

The facility to evaluate the orbital ana­tomy "in vivo" by computed tomographic (CT) scanning has opened discussion on the pathogenetic mechanism of various orbito­pathies. In investigating patients with prop­totic eyes, CT evidence of the simultaneous presence of ocular and orbital infiltrative lesions should suggest orbital extension of intraocular tumours (retinoblastoma or cho­roidal melanoma), metastatic tumour to the eye and orbit or infiltrative lymphomatous or leukaemic deposits[1]. In bilateral cases, how­ever the latter is the strongest probability.

It is extremely rare for a patient with sys­temic lymphoproliferative disorder to seek initial ophthalmic consultation. Only 3 of 1269 patients in Rosenberg[2] series did so, although another 13 patients developed prop­tosis during the course of their disease. More­over, proptosis as an initial presentation of acute myelogenous leukaemia is a chance finding in ophthalmic practice[1],[3],[4],[5],[6],[7],[8]. We report the case of a 8 year old girl who was investi­gated by us for bilateral proptosis. Demons­tration of bilateral concurrent ocular and orbital affections with characteristic infiltra­tion of the optic nerves suggested the possi­bility of biorbital leukaemic infiltration. The diagnosis was confirmed by haematological studies. CT evidence of diffuse optic nerve infiltration warranted urgent orbito-cranial irradiation in combination with systemic che­motherapy for protecting vision. In post therapy check scans, CT evidence of impro­vement preceded the clinical amelioration and regression of proptosis indicating excel­lent therapeutic response. The role of CT in evaluating patients with infiltrative orbito­pathy and in monitoring the results of therapy is discussed at length with the review of available literature.


  Case report Top


LP, an 8 year old girl presented with bilateral progressive proptosis since one month. She gave no history of headache, vomiting, fever or episodic bleeding and had not sustained trauma to-head in the recent past. Physical examination was unremarkable except for puffiness of the face and bilateral proptosis eyes [Figure - 1]. Ab­dominal examination revealed no viscerome­galy, bone tenderness elicited on sternal pressure was questionable. Ophthalmic evalu­ation revealed bilateral, axial, noninflamma­tory proptosis with passive and uniform restriction of ocular mobility, examination of the external ocular segments revealed no abnormality.

Both eyes had visual acuity reduced to 6/24, intact peripheral visual fields and papil­loedema on fundoscopy.

Skull radiographs including lateral, Waters and Caldwell view were unremarkable. Com­puted tomographs demonstrated bilateral diffuse ocular and orbital infiltrations within the intraconal area with masses of soft tissue attenuation obliterating the global anatomy. Both the optic nerves appeared dense, expan­ded with increased attenuation and showed no change with contrast enhancement [Figure - 2] Bilateral secondary infiltrative orbitopathy was suggested and acute myeloid leukaemia was diagnosed by haematological studies.

Systemic manifestations of 'the disease how­ever, developed subsequently. Biorbital irra­diation was combined with the conventional chemotherapy for infiltrative optic neuro­pathy. Regression of proptosis was marked within 10 days [Figure - 3] however, CT evidence of clearing of infiltrations preceded the clinical recovery [Figure - 4].


  Discussion Top


Patients with acute myeloid leukaemia presenting with proptotic eyes as the initial systemic manifestation of the disease are rarely encountered in Ophthalmic practice. Computed orbital tomography in such cases not only defines the anatomical extent and nature of the lesion but often gives a clue to search for an offending systemic pathology which has not yet declared itself clinically, as noted in the present case.

The common orbital disorders which show concurrent involvement of the eye and orbit on a CT display include invasive intra global tumours (retinoblastoma and choroidal mela­nomal[1],[9],[10],(11),(12)), metastases especially from the breast or bronchus and haematological disor­ders including lymphoid hyperplasia, lym­phomas and leukaemias.[1],[3] Other neopla­sms capable of concurrent presentation within the eye and orbit are rare but include medulloepithelioma, glioma of optic nerve, carcinoma of the nonpigmented ciliary epi­thelium and squamous cell carcinoma of the conjunctiva.

In patients with orbitopathy showing CT evidence of ocular and periocular affection, systemic evaluation must be carried out for lymphoma or leukaemia and to differentiate distance orbital metastases from invasive primary ocular tumours[1].

CT demonstration of global infiltrations with expansion of the intraorbital optic nerves has been described to be characteris­tic of leukaemic orbitopathy.

In the presence of papilloedema or visual failure, demonstration of optic nerve infil­tration in CT warrant the need for aggressive management with chemotherapy and orbito­cranial irradiation. Such combined therapy is popular in the management of concurrent ocular and periocular infiltrative orbitopa­thies.

However, visualization of an expanded optic nerve at CT in a patient with failing vision and atrophic optic disc prognosticates poor post therapy visual recovery.

Follow up CT studies can be dictated by the clinical course, but in view of the possible risk of radiation exposure as few scans should be done as appears practical. Check scan­ning should be reserved for patients who show' poor post therapy recovery in whom visual deterioration progresses in spite of aggressive therapy or when orbital recurrence is suspec­ted during follow up period.


  Summary Top


The case of an 8-year old girl developing bilateral proptosis as the initial manifesta­tion of acute myeloid leukaemia is presented and the characteristic computed tomographic finding of infiltrative orbitopathy is discussed. CT has the advantage of imaging both the bone and soft tissue structures within the orbit noninvasively. Demonstration of the nature and extent of orbital invasion significantly alters the differential diagnosis of various orbital disorders and changes the management and prognosis as exempli­fied in our patient with biorbital leukaemic infiltration.

 
  References Top

1.
Grimson B S.. Cohen KL and Carney W.H., 1982, J. Comput. Assist. Tomogr. 6(3): 617.  Back to cited text no. 1
    
2.
Rosenberg S.A.. Diamond H.D., Jaslowitz, B. and Carver, I.D., 1961. Medicine 40:31.  Back to cited text no. 2
    
3.
Ratn, S. and Misra. M, 1982, Orissa Medical Journal (OMJ) 1 (4): 119.  Back to cited text no. 3
    
4.
Crombie, AL, 1967, Brit. J. Ophtbalmol, 51, 101  Back to cited text no. 4
    
5.
Seal, G.N. and Gupta A.K., 1973, Ind. J. Oph­thalmol.. 21:73.  Back to cited text no. 5
    
6.
Bajal, G.C., Agarwal NL.. Charu Gowende and Gunta DC., 1979. Ind. J. Ophthalmol. 26:53  Back to cited text no. 6
    
7.
Hesselink, JR and Weber, AL., 1982, J. Comput Assist. Tomogr., 6 (3): 593  Back to cited text no. 7
    
8.
Panda, A and Dayal, Y., 1984, Ind. J. Ophthalmol , 34: 239  Back to cited text no. 8
    
9.
Harrison, T.R., 1974, Principles of internal medicine, Graw Hill, Kogakusha Ltd., 7th ted.   Back to cited text no. 9
    
10.
Karp, LA, Zimmerman, LE, Payne, NE, 1971, Arch. Ophthalmol. 82: 295.  Back to cited text no. 10
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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