Ophthalmic Manifestations of Chronic Myeloid Leukemia As Initial Presentation and Unmet Needs
Authors: Mohamed Shehab , Nashwan Abdulqadir Jeprel , Qatami Ahmed , Yassin Mohamed A 
Published: October 2019

Abstract
Chronic myeloid leukaemia (CML) is myeloprofilative neoplasm classically described as triphasic disease (chronic, accelerated and blast) and despite the significant efforts done by different groups to optimize treatment and outcome, still there is unmet needs and unanswered questions. Ophthalmologic Manifestations, is one of therapeutic challenges, the best available therapy for patient presenting with Ophthalmologic Manifestations, still unclear.
One of the Uncommon presentation of CML is Ophthalmologic Manifestations which can can be variable from incidental finding during eye examination to blurred vision and partial or total loss of vision.There is paucity in the literature and a little is known about it, How it present? is ophthalmic examination for each patient newly diagnosed with CML is amust? Is there is cut off for leukocytosis which can predict eye damage?.
Reversibility of this complications important from patient perspective, as well as both hematologist and ophthalmologist.
The ophthalmological manifestations itself could have wide range of presentation and finding upon fundoscopy and eye examination. The pathological complications on the eye could be reversible or irreversible. The irreversible could be urgent like retinal hemorrhage or non-urgent like cotton wool spots, infections or proptosis.
. Patients with ophthalmic manifestation of CML have been reported to have lower than 5-year survival rates
Leukemic infiltrates most often affect the choroid; however, these are difficult to detect clinically and may present with a serious or exudative retinal detachment. Additionally, pallor and swelling of the optic nerve may indicate optic nerve infiltration and require immediate referral.
By reviewing the literature, we found only 10 cases were reported to have ophthalmic manifestations . In 80 % of the cases eye symptoms and signs were first presentation of CML. The remaining were relapse. We notice The WBC average from (150- 450,000).
There is no cut off in the literature for Hyperviscosity , neither for ophthalmological finding to happen. We observe from the cases review, all of them have had WBC at least more than 150,000.
There no consensus to treat those patients, 10 % treated with surgery alone and another 10 % with radiotherapy alone, both scenarios were beforeTKI era. The remaining percentage of around 80% treated with combination of eye surgery with cytoreduction and TKI. Those patient who treated have had improved or resolved outcome..
We recommend base line fundoscopy and eye examination by ophthalmology as base line for all patients with new diagnosis of CML and WBC more than 150 on presentations or in the presence of symptoms or signs of ophthalmic manifestation.We believe that early intervention can save the patient eye. however base on reviewing the previous cases and input from ophthalmolopgist we proposed the following criteria (table)when doing eye exam to differentiate between the reversible versus irreversible since that can make big difference (table 1) and guiding the hematologist whether to use cytoreduction or to go ahead and do Leukopharesis ,however further prospective studies are needed to this unmet needs address and to consolidate the previous findings

Disclosures
No relevant conflicts of interest to declare.