Multimodal imaging in a case of presumed secondary vitreoretinal lymphoma presenting with inner retina and optic nerve head infiltration

Abstract

Purpose: To report the findings supported by multimodal imaging in a case of secondary vitreoretinal lymphoma presenting with inner retina and optic nerve head infiltration.

Observations: A 64-year-old man with systemic diffuse large B-cell lymphoma presented with reduced visual acuity. Moderate anterior chamber and vitreous cell were present. Fundus exam showed bilateral disc edema and diffuse opaque macular infiltrates with a pseudo cherry-red spot in the left eye. Optical coherence tomography showed inner retinal infiltration and loss of normal architecture. Surgery for tissue biopsy was discussed and declined due to risk. Instead, multimodal imaging and anterior chamber fluid sampling were used as a surrogate for tissue biopsy and helped rule out infectious uveitis and retinal vascular disease. The patient was empirically treated with intravitreal methotrexate with rapid improvement in vision, exam, and quality of life.

Conclusions and importance: Multimodal imaging can support a presumed diagnosis of secondary vitreoretinal lymphoma in order to proceed with intravitreal methotrexate treatment, which can result in rapid clinical and visual improvement.

Keywords: Intravitreal methotrexate; Multimodal imaging; Optical coherence tomography; Retina; Vitreoretinal lymphoma.

Fig. 1

Multimodal imaging at initial presentation. Color fundus photos show areas of diffuse macular and peripapillary whitening OU and retinal hemorrhages OD (A, B). OCT revealed retinal thinning, loss of outer retinal layer architecture, and vitreomacular traction OD (C) with diffusely thickened hyperreflective inner retinae through areas of macular whitening OD (D) and OS (E). Optic nerve OCT reveals peripapillary extension of infiltration OU. FA of the right eye reveals blockage from retinal hemorrhages and progressive late leakage of the disk and along the superior arcade (H–J), as well as extensive mid and late-phase disc and macular leakage in the left eye (K–M).

Fig. 2

OCT after first round of intravitreal methotrexate injections. OCT through the fovea of the right eye showed persistent vitreomacular adhesion (A) but there was profound recession of inner retinal infiltration corresponding to areas of macular whitening OU (B, C).