History of present illness

A 62-year-old man noted floaters in both eyes for a few months. He described some headaches as well. He had been in good health otherwise and previously underwent cataract surgery with intraocular lens implantation 4 years ago in both eyes.

Ocular examination findings

Visual acuity with correction was 20/20 in both eyes. Intraocular pressure was normal. External and anterior segment examination showed posterior chamber lens implant with cells in the anterior vitreous ( Fig. 64.1 A, B). Dilated fundus examination revealed cells in the vitreous of both eyes.

(A) Note the large cells in the anterior vitreous right behind the posterior chamber implant. (B) A posterior capsulotomy, behind which are still vitreous strands with cells attached to the fibrous strands.

Imaging

Optical coherence tomography (OCT) showed cells on the surface of the retina in both eyes and no cystoid macula edema (CME) ( Fig. 64.2 ).

Optical coherence tomography showing cells on the surface of the retina and extending into the vitreous.

Questions to ask

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  Is the patient immunocompromised?

  
  
  
  
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    No, but if he were younger, then the odds of being immunocompromised would be higher.

  
  
  
  
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  Has the patient had chronic lymphocytic leukemia (CLL)?

  
  
  
  
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    No. CLL carries a chance of Richter transformation, which is associated with diffuse large B-cell lymphoma (DLBCL).

  
  

Assessment

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  This is a case of a 62-year-old man with headaches and cells in the vitreous of both eyes and no cystoid macular edema.

Differential diagnosis

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  Bilateral endogenous endophthalmitis

  
  
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  Tuberculosis

  
  
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  Syphilis

  
  
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  Birdshot chorioretinitis

  
  
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  Vitreoretinal lymphoma (VRL)

  
  
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  Intermediate uveitis

  
  
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  Whipple disease

Working diagnosis

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  VRL. The presence of vitreous cells in the absence of macular edema should increase the probability of VRL. Most commonly, VRL is bilateral, and the chance of central nervous system (CNS) involvement is greater with bilateral cases. Careful determination is needed to be sure that unilateral disease is truly present.

Multimodal testing and results

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  Ultrasonography

  
  
  
  
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    Ultrasonography shows cells in the vitreous, and there can be cells in the Berger space by ultrasound biomicroscopy ( Fig. 64.3 ).

    
    

    
    

    
    

    

    
    

    
    

    Ultrasonography showing a posterior vitreous detachment, in which cells are present.

    
    

  
  
  
  
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  Fundus photographs

  
  
  
  
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    On fundus examination, with VRL, there can be cells in the vitreous and/or cells under the retinal pigment epithelium (RPE), or under the retina ( Fig. 64.4 , Fig. 64.5 ).

    
    

    
    

    
    

    

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