Katherine E. Talcott

Ophthalmic manifestations of leukemia.

Purpose of review This article aims to describe the ocular manifestations of leukemia, resulting both from direct infiltration of neoplastic cells and from the more common secondary effects of leukemia and its treatment. The prevalence of these findings is also discussed, along with their clinical significance, association with hematologic markers and the ophthalmologists role caring for these patients. Recent findings Recent studies have included a large case series examining the prevalence of ocular manifestations in newly diagnosed leukemic patients as well as case reports of ocular manifestations of leukemia. Summary Patients with leukemia often have ocular manifestations. These occur either from direct infiltration of neoplastic cells or from indirect or secondary causes, including hematologic abnormalities, central nervous system involvement, opportunistic infections, or from treatment. Although nearly all ocular structures can be affected, leukemic retinopathy is often the most clinically apparent manifestation. Awareness of the ophthalmic manifestations of leukemia is important as they may precede systemic diagnosis or may be a sign of leukemia recurrence.

Case 49: Corneal Ulcer Associated with Sutures After Zone I/II Open Globe Injury

An 80-year-old man presented with a Zone I-II open globe injury of the left eye from a metal chair clip. The corneal laceration was complex and stellate. Following repair, the patient developed a corneal ulcer related to loose sutures. He was treated with topical antibiotics, and although the infection resolved, he was left with a large corneal scar, ultimately requiring penetrating keratoplasty. In this patient, the development of a corneal infection around loose sutures was likely a result of the difficult-to-close complex stellate wound.

Case 28: Zone I/II Open Globe Injury with Corneal Patch Graft and Corneal Glue

A 53-year-old man was struck in the right eye by barbed wire that he was cutting under tension while working on a fence. He was found to have Zone I-II open globe injury and underwent surgical repair. He was initially taken to an outside hospital in the late afternoon before being transferred to MEE for further management of his eye trauma. Between the time of his initial injury and open globe repair (which was approximately 17 h), his cornea became increasingly necrotic, making direct suture repair difficult. This necessitated a corneal patch graft, corneal glue, cultures, pathology, and intracameral antibiotics. The glue was subsequently removed over several clinic visits, and the patient healed well.

Case 50: Sympathetic Ophthalmia After Open Globe Repair

A 53-year-old man presented with a zone III ruptured open-globe of the left eye from a spring-loaded piece of an antique car door. Examination was notable for a 20 mm temporal scleral rupture extending posteriorly with uveal prolapse. The patient underwent repair of this open-globe injury followed by pars plana vitrectomy (PPV) for retinal incarceration and retinal detachment with a giant retinal tear and repeat PPV for anterior chamber intraocular lens placement. Two months following his second PPV, he presented with a visual acuity of 20/400 in the right eye and found to have panuveitis and serous retinal detachments of the right eye. The patient was diagnosed with sympathetic ophthalmia and started on high dose steroid therapy and mycophenolate. His visual acuity returned to 20/20 in the right eye 1 month after starting therapy. Sympathetic ophthalmia, a bilateral granulomatous panuveitis, is a rare condition that can occur after ocular trauma or intraocular surgery. Counseling patients about the risk of sympathetic ophthalmia should occur prior to performing open-globe repair.

Case 45: Endophthalmitis After Open Globe Injury Repair

A 45-year-old man presented with a Zone I open globe injury of the right eye after being struck by a rock and had prompt surgical repair of the open globe injury within 7 h of his injury. Despite hospital admission for intravenous antibiotics, the patient developed high intraocular pressure post-operatively and a hypopyon was seen on post-operative day 3. He was promptly referred to a retinal specialist and underwent intravitreal tap and injection of antibiotics. Six months after the initial injury, the patient underwent cataract extraction with pupilloplasty. He obtained excellent visual recovery, with a visual acuity of 20/20 1 year after his initial presentation.

Case 32: Delayed-Presentation Zone I/II Open Globe Injury Requiring Corneal Glue

A 41-year-old man presented with a delayed Zone I–II open-globe injury of the right eye from hitting his eye on a vacuum cleaner handle. CT imaging was consistent with an open-globe injury, and no intraocular lens was seen on the right on clinical exam or imaging. Due to the delayed presentation, the tissue surrounding the wound was very friable and was unable to be closed with sutures alone without a wound leak. Corneal glue was placed over the wound intraoperatively. After the cornea glue fell off a few weeks postoperatively, the wound was noted to be Seidel negative. The corneal sutures were left in place for an extended period given the complex closure requiring corneal glue. Sutures were removed under anesthesia due to patient cooperation. The final vision was 20/50 that improved with pinhole to 20/20 with an anterior chamber intraocular lens. This case emphasizes the importance of having options available intraoperatively in delayed-presentation cases as the tissue surrounding the wound may be friable and abnormal making closure difficult with sutures alone.

Case 29: Traumatic Evisceration

A 34-year-old man presented after a metal wheel grinder struck his left face, and was found to have extensive facial fractures, periorbital soft tissue lacerations and a severely deformed left globe. Due to extensive globe injury, a preoperative discussion and consent for possible primary evisceration with ocular implant placement and facial reconstruction was undertaken with the patient. Surgical exploration revealed an unsalvageable globe. Intraoperatively the patient’s ruptured scleral tissue was identified, but there was complete absence of intraocular contents, indicating no chance of vision restoration. An implant was placed in the scleral shell and the extensive facial fractures and soft tissue injuries were repaired by the oculoplastic service, yielding an excellent cosmetic result. Primary implant placement can be considered during the initial surgery in patients with traumatic evisceration without chance of vision restoration.

Case 41: Zone I Open Globe Injury with Retained Corneal Foreign Body and Lens Capsule Violation

A 31 year-old man suffered a full-thickness corneal laceration with retained wooden foreign body lodged into his cornea. He was transferred from an outside hospital to a dedicated eye hospital, which imposed a delay in open globe repair and wooden foreign body removal. His open globe repair was uneventful but his initial injuries included capsular violation that resulted in rapid cataract formation and an increase in eye pressure, necessitating cataract removal. He subsequently underwent lens implantation. This case highlights precautions in open globe repairs with high risk for endophthalmitis as well as an approach to cataract surgery after open globe injury with capsular violation.

Case 46: Wound Leak After Open Globe Repair Requiring Corneal Glue and Re-suturing

A 28-year-old man presented with a Zone I open globe injury and an intraocular metal foreign body in the left eye. The metal foreign body was removed and the open globe was repaired. At the end of the case a slow wound leak was noticed and a bandage contact lens was placed. On post-operative day 1 the anterior chamber was shallow and the wound leak was sealed with corneal glue. Two weeks later the glue came loose and the wound leak persisted necessitating repeat corneal glue. Eight weeks post-operatively, the glue loosened and was removed along with the underlying sutures, and a wound leak was still present. The patient was taken to the operating room where the wound edges and overlying epithelium were debrided and the wound was re-sutured. After re-suturing, the wound remained watertight. Ten weeks after re-suturing, the corneal sutures were removed without complications, with a final visual acuity of 20/15.

Case 16: Zone I/II/III Open Globe Injury with Retinal Strike Site and Post-operative Strabismus

A 13-year-old boy presented with a Zone I-II-III open-globe injury of the left eye secondary to an accidental pocketknife injury while at camp. The patient underwent primary repair of the injury, which required hooking and isolating the inferior rectus muscle and repositioning of prolapsed uvea. The patient subsequently required a pars plana vitrectomy, lensectomy, endolaser and membrane peel. With improvement in vision to 20/40 with a contact lens, the patient developed binocular diplopia from a moderate-angle, sensory exotropia. He underwent a left lateral rectus recession and left medial rectus recession with improvement in the cosmetic appearance of his eyes but not complete resolution of his diplopia.