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Hematology

Middle-aged Man With Bilateral Subretinal Fluid

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Ophthalmology

January 1, 2019

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Kareem Moussa, MD¹;

Michael Bradbury, MD²;

David M. Wu, MD, PhD¹

Author Affiliations

¹Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
²Retina Consultants of Worcester, Worcester, Massachusetts

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A man in his mid-50s presented with painless blurry vision in the left eye. According to the patient’s report, he had experienced this vision abnormality in the left eye for 1 week. At presentation, visual acuity was 20/20 OD and 20/400 OS. Results of a dilated fundus examination were normal in the right eye and notable for a macular serous retinal detachment in the left eye (Figure 1A). Findings on optical coherence tomography (OCT) showed a dome-shaped collection of subretinal fluid in the macula (not shown). Late-phase fluorescein angiography revealed multifocal pinpoint areas of hyperfluorescence with mild leakage within the area of detachment (Figure 1B).

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Acute myeloid leukemia

B. Order a complete blood cell count

The patient started treatment with oral prednisone, 60 mg/d. Test results for syphilis, tuberculosis, and sarcoidosis were negative. One week later, the patient presented with fatigue and shortness of breath. A complete blood cell count revealed a white blood cell count of 90 000 cells/μL (reference range, 4500-10 000 cells/μL) (to convert to ×10⁹ per liter, multiply by 0.001). A bone marrow biopsy specimen showed immature myeloid cells, which prompted a diagnosis of acute myeloid leukemia (AML).

Ocular involvement in AML is common, occurring in 73% to 89% of eyes according to a postmortem study.¹ Involvement of the retina is found more frequently than other ocular tissues. Typical manifestations of ocular involvement include retinal hemorrhages and dilation as well as tortuosity of the venules.²

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Article Information

Corresponding Author: David M. Wu, MD, PhD, Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114 (david_wu@meei.harvard.edu).

Published Online: November 8, 2018. doi:10.1001/jamaophthalmol.2018.2759

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

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Agarwal A, Gass JDM. Gass’ Atlas of Macular Diseases. 5th ed. Edinburgh, Scotland: Elsevier Saunders; 2012.

Kim J, Chang W, Sagong M. Bilateral serous retinal detachment as a presenting sign of acute lymphoblastic leukemia. Korean J Ophthalmol. 2010;24(4):245-248. doi:10.3341/kjo.2010.24.4.245 PubMed Google Scholar Crossref

Yoshida A, Kawano Y, Eto T, et al. Serous retinal detachment in an elderly patient with Philadelphia-chromosome-positive acute lymphoblastic leukemia. Am J Ophthalmol. 2005;139(2):348-349. doi:10.1016/j.ajo.2004.07.043 PubMed Google Scholar Crossref

Stewart MW, Gitter KA, Cohen G. Acute leukemia presenting as a unilateral exudative retinal detachment. Retina. 1989;9(2):110-114. doi:10.1097/00006982-198909020-00007 PubMed Google Scholar Crossref

Yang HK, Yu HG. Acute lymphoblastic leukemia manifesting as acute Vogt-Koyanagi-Harada disease. Korean J Ophthalmol. 2009;23(4):325-328. doi:10.3341/kjo.2009.23.4.325 PubMed Google Scholar Crossref

Smith AG, London NJS, Pao K, Lipkowitz J, Kurup SK, Garg SJ. Leukemia presenting as serous retinal detachment. Retin Cases Brief Rep. 2014;8(4):279-282. doi:10.1097/ICB.0000000000000074 PubMed Google Scholar Crossref

Grewal DS, Chiang E, Wong E, Volpe NJ, Bryar PJ. Adult ophthalmology inpatient consults at a tertiary care teaching hospital. Ophthalmology. 2014;121(7):1489-1491.e1. doi:10.1016/j.ophtha.2014.01.010 PubMed Google Scholar Crossref

Middle-aged Man With Bilateral Subretinal Fluid

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Middle-aged Man With Bilateral Subretinal Fluid

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