NEWS & EVENTS
Retinal Review, Issue 18
CASE NUMBER 18
An 84 year old woman was evaluated for vision loss in her right eye. Past medical history is significant for diabetes and hypertension. Ocular history is significant for cataracts and macular degeneration. She was unaware of a vision problem, but her optometrist noted significant visual loss during a routine evaluation.
On examination visual acuity measured OD: 20/400 and OS: 20/25. IOP’s and the slit lamp examination were normal. Amsler grid testing showed diffuse metamorphopsia of the right eye and was full in the left. There were mild cataracts in both eyes. Dilated examination is as follows:
The patient had moderate dry AMD in the left eye with multiple drusen and geographic RPE disease. In the right eye there was exudation throughout the macula and around the optic nerve. Although there can be broad exudation with wet AMD, it is unusual to have this much fluid in so large an area. Additionally, there was an unusual RPE pattern in the right eye and possibly the left. B scan ultrasonography confirmed shallow retinal detachment in the macula of the right eye. We elected to observe for a few weeks to see if there would be a resolution or worsening of the maculopathy. The follow up examination was unchanged.
The differential diagnosis for yellowish lesions with exudative fluid in an 84 year old include wet AMD variant vs inflammation (white dot syndrome such as birdshot chorioretinitis) vs infection vs autoimmune disease vs neoplasm. The findings of yellowish subretinal exudates, exudative retinal detachment and unusual RPE marking suggest the possibility of ocular lymphoma. We elected to proceed with a diagnostic vitrectomy, neuroimaging and blood work. The post operative course was uneventful. Vision remained 20/400 OD and the retina was stable.
To our surprise the testing was all normal. There was no sign of lymphoma in the vitreous fluid, blood tests or MRI. The only other test that was considered was a spinal tap but the patient refused further testing. Ocular lymphoma can be difficult to diagnose in that there is limited vitreous fluid. Sometimes observation is warranted if the original testing fails to conclusively demonstrate neoplastic cells. The vision has remained stable for the past twelve months and we will continue to monitor her carefully. If further signs of lymphoma develop she will be referred for chemotherapy or radiation.