Diagnostic dilemma of ocular lymphoma

Abstract

We report a very unusual presentation of primary intraocular lymphoma masquerading as anterior uveitis with atypical symptoms. A 68-year-old man, initially presented with a 4-day history of painless, left blurred vision. Examination revealed 2 or more anterior chamber cells, mutton-fat keratic precipitates and posterior synechiae. Treatment was initiated, the eye settled, and the patient was discharged. He re-presented 7 months later with hypopyon, a hazy cornea, fibrin deposits and a narrowed anterior chamber angle. Over the coming weeks, it became apparent that the temporal iris was thickened, involving the angle, and his intraocular pressure increased despite topical dorzolamide. Following advice from a tertiary centre and referral to a regional ocular oncology centre, a transscleral biopsy was performed and suggested a ciliary body melanoma. Enucleation was advised and performed, with histological examination revealing features consistent with an ocular diffuse large B-cell lymphoma not involving the optic nerve, sclera or cornea. This is the first ever published report of a case of ocular lymphoma masquerading in this way.

Keywords: CNS cancer; anterior chamber; iris.

Figure 1

Colour photograph of the left eye anterior segment demonstrating thickening of the temporal iris with shallowing of the anterior chamber.

Figure 2

Colour photograph of the left eye anterior segment demonstrating posterior synechiae, keratic precipitates and rubeosis; all features typical of acute anterior uveitis.

Figure 3

Optical coherence tomography image of the macula of the normal right eye.

Figure 4

Optical coherence tomography image of the macula of the abnormal left eye. Similarity of images and absence of macular oedema is a clue that this is not a typical inflammatory process.