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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

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
1.
Kincaid  MC, Green  WR.  Ocular and orbital involvement in leukemia.  Surv Ophthalmol. 1983;27(4):211-232. doi:10.1016/0039-6257(83)90123-6PubMedGoogle ScholarCrossref
2.
Agarwal  A, Gass  JDM.  Gass’ Atlas of Macular Diseases. 5th ed. Edinburgh, Scotland: Elsevier Saunders; 2012.
3.
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.2010.24.4.245PubMedGoogle ScholarCrossref
4.
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.2004.07.043PubMedGoogle ScholarCrossref
5.
Stewart  MW, Gitter  KA, Cohen  G.  Acute leukemia presenting as a unilateral exudative retinal detachment.  Retina. 1989;9(2):110-114. doi:10.1097/00006982-198909020-00007PubMedGoogle ScholarCrossref
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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.2009.23.4.325PubMedGoogle ScholarCrossref
7.
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.0000000000000074PubMedGoogle ScholarCrossref
8.
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.2014.01.010PubMedGoogle ScholarCrossref
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