Bilateral retinal detachment after chimeric antigen receptor T-cell therapy

Abstract

1. CAR T-cell targeting of leukemic infiltrates in the optic nerve and retina caused retinal detachment as a presentation of pseudoprogression.

2. Treatment of this intraocular inflammation with intravitreal triamcinolone and orbital radiation led to marked improvement in visual acuity.

Graphical abstract

Figure 1.

Ocular findings at presentation and following treatment with CAR T-cell therapy. (A-D) Color fundus photography and fluorescein angiography at presentation. (A) The right eye features optic disc infiltration and leukemic retinal infiltrates and hemorrhages. (B) The left eye has leukemic disc infiltration, as well as scattered retinal infiltrates sparing the macula. (C) Fluorescein angiography of the right eye shows minimal perfusion of the choroidal and retinal circulations. (D) The left eye has relatively maintained choroidal and retinal vascular filling, with blockage in areas of leukemic infiltration and hemorrhage. (E-F) Color fundus photography following CAR T-cell therapy. The right (E) and left (F) eyes demonstrate worsened retinal whitening, hemorrhages, and optic disc edema with total exudative retinal detachments. (G) Ocular ultrasound of the right eye demonstrates subretinal fluid (arrowhead) without evidence of choroidal involvement. (H) Flow cytometry of the right aqueous humor demonstrates a predominance of CD3⁺CD19⁻ cells.

Figure 2.

Multimodal retinal imaging at 18 months post–CAR T-cell therapy. (A) The right eye has severe optic disc pallor, diffuse retinal atrophic changes, and sclerotic vessels. (B) The left eye has moderate-severe optic disc pallor and retinal atrophic changes. (C-D) The retina is entirely attached in both eyes. Fundus autofluorescence shows bilateral stippled and nummular areas of hyper- and hypoautofluorescence representing areas of photoreceptor and retinal pigment epithelium damage. Late-phase fluorescein angiography reveals peripheral window defects in the right eye (E) that are more common than in the left eye (F) with staining of the disc bilaterally. (G) Spectral-domain optical coherence tomography shows diffuse photoreceptor loss in the right macula. (H) The left macula has relative preservation of the photoreceptor bands and corrugation of the inner retina.