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EXPEDITED PUBLICATION, PHOTO ESSAY
Year : 2021  |  Volume : 69  |  Issue : 3  |  Page : 768-769

Blurring of vision as the only symptom in an undiagnosed case of chronic myeloid leukemia in the COVID-19 era


Sarojini Devi Eye Hospital, Osmania Medical College, Hyderabad, Telangana, India

Date of Submission07-Dec-2020
Date of Acceptance16-Jan-2021
Date of Web Publication17-Feb-2021

Correspondence Address:
Dr. Rajalingam Vairagyam
Superintendent's Office, Sarojini Devi Eye Hospital, Mehdipatnam, Hyderabad - 500028, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3629_20

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  Abstract 


Keywords: CML, Roth spots, Submacular hemorrhage, T. Dasatinib, Nepafenac eyedrops


How to cite this article:
Gumaste P, Vairagyam R. Blurring of vision as the only symptom in an undiagnosed case of chronic myeloid leukemia in the COVID-19 era. Indian J Ophthalmol 2021;69:768-9

How to cite this URL:
Gumaste P, Vairagyam R. Blurring of vision as the only symptom in an undiagnosed case of chronic myeloid leukemia in the COVID-19 era. Indian J Ophthalmol [serial online] 2021 [cited 2021 Feb 24];69:768-9. Available from: https://www.ijo.in/text.asp?2021/69/3/768/309413



A 32-year-old man presented with complaints of bilateral blurring of vision for 1 week. Snellen's chart BCVA (OD) 6/60 (OS) Counting Fingers-2m. Fundus examination revealed, bilateral blurred disc margins, hemorrhages on optic disc and peripapillary region, Roth spots in all four quadrants, and large submacular hemorrhage (OS > OD). [Figure 1]a and [Figure 1]b Fundus Fluorescein Angiography showed hyperfluorescent disc, mild venous tortuosity, hyperfluorescent spots around vessels, blocked fluorescent areas suggestive of intraretinal, subretinal hemorrhages and submacular hemorrhage [Figure 1]c and [Figure 1]d Optical Coherence Tomography: intraretinal and submacular hemorrhage (OS > OD) [Figure 2]b and [Figure 2]c. Vitals stable. No clinical findings were seen on systemic examination. We investigated CBC and Peripheral blood smear. Total WBC count was 3,37,610 cells/cumm2 and on smear anisocytosis, mild leukocytosis with lymphocytic predominance was seen. Bone marrow aspiration showed severe leukocytosis with shift to left with presence of precursor forms and absolute basophilia (10%), blasts: 02%, thrombocytopenia (Platelets: 70,000/ul). Chromosomal analysis: BCR-ABL was detected. After oncology opinion, the patient was started on T. Dasatinib and Nepafenac eyedrops. On 2 months follow up, we noticed that retinal hemorrhages, submacular hemorrhage were resolving and optic disc undergoing gliosis [Figure 3]a and [Figure 3]b Follow up at 3 months showed that the intraretinal and submacular hemorrhages were resolving significantly [Figure 3]c and [Figure 3]d. Chronic myeloid leukemia (CML) is a clonal myeloproliferative disorder of a pluripotent stem cell.[1] Retinal changes in leukemias may be related to direct invasion of tissue by neoplastic cells; or to manifestaions of associated hematologic abnormalities such as anemia, thrombocytopenia, or hyperviscosity states; to opportunistic infections; or to unrelated chance findings.[2]
Figure 1: (a) right eye and (b) left eye: Colour Fundus Photograph: blurred disc margins, hemorrhages on optic disc and in peripapillary region, roth spots in all the four quadrants, submacular hemorrhage (OS > OD). (c) right eye and (d) left eye: Fundus Fluorescein Angiography: hyperfluorescent disc, mild venous tortuosity, hyperfluorescent spots around vessels, blocked fluorescent areas suggestive of intraretinal, subretinal hemorrhages and submacular hemorrhage

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Figure 2 : (a) Fundus Fluorescein Angiography: mild venous tortuosity, hyperfluorescent spots around vessels. (b) right eye (c) left eye: Optical Coherence Tomography: intraretinal and submacular hemorrhage (OS > OD)

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Figure 3: Colour Fundus Photograph: (a) right eye (b) left eye. Follow up at 2 months: resolving retinal hemorrhages, submacular hemorrhage resolving and optic disc undergoing gliosis. (c) right eye (d) left eye: Follow up at 3 months: The intraretinal and submacular hemorrhages were resolving significantly

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  Discussion Top


Ophthalmic manifestation being the first and only symptom in a case of CML is a rare entity.[3],[4] Often poor prognosis is expected in large submacular hemorrhages and known to have a fivefold relative risk of developing an intracranial hemorrhage.[2]

As pandemic was at its peak and the country was experiencing a massive lockdown, the patient was fearful to undergo investigations. However, even with the unfortunate delay at each step, with patient counseling we managed to diagnose the condition. We emphasize that meticulous ocular examination and basic peripheral blood picture not only helps in significant visual improvement but can be lifesaving and provides a better quality of life as in our case despite the pandemic.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Priya BV, Jain K, Mahendradas P, Shetty BK. “String of beads” appearance on fundus fluorescein angiopathy as a clinical clue for leukemia-related proliferative retinopathy. Indian J Ophthalmol 2019;67:2049-51.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Ryan's Retina 6th ed. 2018 [Part 2; Section 3; Chapter 159; Page 2661,2666].  Back to cited text no. 2
    
3.
Huang PK, Sanjay S. Visual disturbance as the first symptom of chronic myeloid leukemia. Middle East Afr J Ophthalmol 2011;18:336-8.  Back to cited text no. 3
  [Full text]  
4.
Mohamed S, Nashwan AJ, Qatami A, Yassin MA. Ophthalmic manifestations of chronic myeloid leukemia as initial presentation and unmet needs. Blood 2018;132(Supplement 1):5454.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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