|ONE MINUTE OPHTHALMOLOGY
|Year : 2018 | Volume
| Issue : 1 | Page : 9
Soft drusen or not?
Carol L Shields1, Elizabeth B Elimimian1, Fairooz P Manjandavida2
1 Wills Eye Hospital, Philadelphia, PA, USA
2 HORUS Specialty Eye Care, and Prabha Eye Hospital and Research Centre, Bengaluru, India
|Date of Web Publication||28-Dec-2017|
Dr. Carol L Shields
Ocular Oncology Service, Wills Eye Hospital, Philadelphia, PA
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shields CL, Elimimian EB, Manjandavida FP. Soft drusen or not?. Indian J Ophthalmol 2018;66:9
| Case|| |
A 55-year-old Caucasian female noted floaters and gradual onset of blurred vision in the right eye (OD) for 5 months. She was found to have retinitis and uveitis, classified as autoimmune retinitis and treated with oral and periocular corticosteroids. After little improvement over 2 months, the patient was referred to rule out the underlying malignancy. On examination, visual acuity was 20/80 OD and 20/30 in the left eye (OS). Intraocular pressures were normal and vitreous was clear in both eyes (OU). There were multiple, large, coalescent soft drusen (retinal pigment epithelium detachment [RPED]) in OU. There was no history of age-related macular degeneration.
| What Is Your Next Step?|| |
- Intravitreal antivascular endothelial growth factor injection
- Biopsy the material underlying the largest RPED
- Photodynamic therapy to the PEDs
- Perform indocyanine green angiography to identify choroidal neovascularization.
| Findings|| |
There were numerous yellow coalescent RPEDs in OD (A) and smaller RPEDs OS (B). On optical coherence tomography (OCT) the multifocal RPEDs were large OD (C) and more subtle OS (D), each with homogeneous sub-RPE debris and mild outer retinal edema. Due to the lack of vitreous cellularity on clinical examination and OCT, trans-scleral fine needle aspiration biopsy of the largest RPED OD was performed and represented necrotic large cell lymphoma, consistent with vitreoretinal lymphoma. Intravitreal methotrexate was advised for globe control. Magnetic resonance imaging of the brain revealed a solitary lesion, scheduled for biopsy and management.
Diagnosis: Vitreoretinal Large-Cell Lymphoma Ou.
Correct Answer: b.
| Discussion|| |
Vitreoretinal large-cell lymphoma is a subtype of primary central nervous system lymphoma that can display OU and brain involvement. This high-grade malignancy often has a stuttering onset with intermittent blurred vision and mild vitreous inflammatory cells, sometimes with “cloudy” paraneoplastic subretinal infiltration, best seen on OCT, as in our case., Ocular management typically involves intravitreal chemotherapy or radiotherapy. Despite ocular control, systemic prognosis is guarded depending on brain involvement. One collaborative study found 5-year cumulative survival of 35% in those with related brain lymphoma versus 68% in those without brain involvement.
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.
| References|| |
Ahmed AH, Foster CS, Shields CL. Influence of location and treatment on survival in diffuse large B-cell lymphoma of the eye and ocular adnexal region. JAMA Ophthalmol 2017;135:1062-8. [doi: 10.1001/jamaophthalmol.2017.3286].
Pang CE, Shields CL, Jumper JM, Yannuzzi LA. Paraneoplastic cloudy vitelliform submaculopathy in primary vitreoretinal lymphoma. Am J Ophthalmol 2014;158: 253-6100.
Riemens A, Bromberg J, Touitou V, Sobolewska B, Missotten T, Baarsma S, et al.
Treatment strategies in primary vitreoretinal lymphoma: A 17-center European collaborative study. JAMA Ophthalmol 2015;133:191-7.