History of Present Illness
A 72-year-old Caucasian male with a 6-year history of primary central nervous system (CNS) lymphoma, confirmed on histopathology of tissue acquired by brain biopsy of the left hemisphere to be diffuse large B-cell lymphoma, presents to the eye clinic with blurred vision of the right eye (OD).
| OD | OS | |
|---|---|---|
| Visual acuity | 20/60 | 20/20 |
| Intraocular pressure (IOP) | 16 | 18 |
| Sclera/conjunctiva | White and quiet | White and quiet |
| Cornea | Clear | Clear |
| Anterior chamber (AC) | Trace cells | Deep and quiet |
| Iris | Unremarkable | Unremarkable |
| Lens | Clear | Clear |
| Anterior vitreous | Vitreous seeding | Clear |
| Nerve: | Pink, sharp | |
| Macula: | Flat | |
| Vessels | Normal caliber and course | |
| Periphery: | Unremarkable |
Questions to Ask
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Do you have any symptoms in the left eye (OS)?
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Have you had any symptoms of shortness of breath, weight loss, neurologic symptoms lymph node enlargement, or any gastrointestinal (GI) symptoms?
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What previous history of lymphoma treatment have you had?
The patient denied any change in vision in the OS. He had neurologic symptoms like headache and seizure that were controlled on medication. He also had a history of significant weight loss and complained of nausea and vomiting. He denied any shortness of breath and did not have any lymph node enlargement. He added that he has had an extensive history of previous management of lymphoma, but did not remember all the details.
Differential Diagnosis
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Secondary vitreoretinal lymphoma
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Infectious vitritis
Working Diagnosis
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Secondary vitreoretinal lymphoma OD
Testing
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With the presence of vitritis, pars plana vitrectomy can be diagnostic. As large a vitreous sample as possible (0.5+ cc) should be sent for polymerase chain reaction (PCR), culture, cytology, and flow cytometry.
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Flow cytometry can be performed to detect clonal B-cell populations.
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To test for infiltrates and retinal detachment, fluorescein angiography and optical coherence tomography (OCT) should be performed ( Fig. 69.2 ).
