Floaters and decreased vision as initial symptoms of acute lymphoblastic leukaemia

A 41-year-old Caucasian man presented with symptoms of decreased vision and numerous floaters in both eyes for over a week, with the left eye being more affected than the right eye. No photopsia or distortion was noted in either eye. He stated that his last eye examination had been 25 years ago and that his medical history was unremarkable, with no medications taken and no drug or other allergies. Refraction resulted in plano/-0.50 ¥ 110 R and +0.50/-0.50 ¥ 072 L, with visual acuities of 6/7.5 R and 6/15 L and no improvement with pinhole in either eye. Ocular motility and pupillary responses were normal for both eyes, with no photophobia. Anterior segment examination was normal, with the exception of a slightly pale appearance to both palpebral conjunctivae. No cells or flare were noted in the anterior chamber of either eye. Intraocular pressures were 18 mmHg in each eye at 4:00 pm. Dilated funduscopic examination revealed clear lenses and vitreous in both eyes, with no signs of vitreous floaters, cells, syneresis or posterior vitreous detachment in either eye. This was in contrast to the patient’s presenting symptom of ‘floaters’. Optic nerve cup-to-disc ratios were 0.20 H/0.20 V with margins of both optic discs being distinct. Numerous dot and blot and flame haemorrhages in all quadrants, dilated and tortuous retinal veins, multiple cotton wool spots and Roth spots were distributed throughout the posterior pole in both eyes (Figures 1A and 1B). Macular oedema, which was more marked in the left eye, was also identified. Subsequent Amsler grid testing revealed diffuse dimming and distortion of grid lines in both eyes, supporting the finding of macular oedema. Blood pressure was 108/63 mmHg (left arm, sitting). Despite detection of these significant fundus signs and possible systemic illness, the patient denied any fatigue, malaise or flu-like symptoms. The physical appearance of his face and body was normal. The patient was informed of the significance of the ocular findings and possible systemic cause secondary to blood abnormalities. The retinal signs (Figures 1A and 1B) suggested ocular ischaemia, probably systemic as both eyes were involved. Blood dyscrasias such as anaemia, leukaemia and thrombocytopenia were possible causes but other diagnoses to consider were severe non-proliferative diabetic retinopathy with clinically significant macular oedema, advanced hypertensive retinopathy (unlikely due to the measured blood pressure), bilateral central retinal vein occlusion, autoimmune-related retinopathy (polyarteritis nodosa, systemic lupus erythematosis, sarcoidosis), anaemia or other blood dyscrasia. The seriousness of these findings was explained to the patient with the recommendation that urgent physical examination and haemaotological tests be undertaken. The patient was immediately referred to his primary care physician for prompt blood tests. Complete blood count revealed a white blood cell (WBC) count over 200,000/mm3 (normal range 3,900 to 10,000/mm), haematocrit at 25 per cent (normal range 38.5 to 49 per cent) and platelet count of 40,000/mm (normal range 140,000 to 390,000 mm). Glucose levels were normal. Based on the retinal findings and blood analysis, a diagnosis of precursor B-cell leukaemia (acute lymphoblastic and lymphocytic leukaemias [ALL]) without central nervous system involvement was made. The patient was admitted to a local hospital for leukapheresis treatment and subsequently transferred to an oncology C L I N I C A L A N D E X P E R I M E N T A L