Authors: Amirthan Sothivannan, Amadeo R. Rodriguez

Author Disclosure Block: A. Sothivannan: None. A.R. Rodriguez: None.

Abstract Body:

Purpose: To describe the neuro-ophthalmic manifestations of lymphoma.

Study Design: Retrospective review of patient charts.

Methods: Between January 2016 and October 2019, we identified five patients whose neuro-ophthalmic manifestations led to either the initial diagnosis of lymphoma, or the identification of recurrent disease. The clinical and radiological findings will be presented.

Results: 1) Hemianopsia as initial manifestation: 74 y.o man with 3 weeks history of blurry vision and missing the left side of sentences from complete left homonymous hemianopia. CT showed large right-sided occipital mass. Biopsy revealed primary CNS diffuse large B-cell lymphoma. 2) Diplopia as initial manifestation: 76 y.o. hypertense woman. Seen for one month history of right pupil-involving CN III. CT-CTA elsewhere no aneurysm, right sided sinusitis. Progressed to diffuse ophthalmoplegia. MRI extensive sphenoid-ethmoidal-maxillary sinus involvement extending to cavernous sinus-skull base, suggestive of osteomyelitis. Started on polymicrobial coverage. Biopsy showed large B-cell lymphoma. 3) Diplopia as first manifestation of recurrent disease: 66 y.o. man. Previous history of Non-Hodgkin’S B-cell lymphoma, diagnosed 9 months prior, treated with CHOP-R. Three months after completing treatment, developed painful right CN III palsy which progressed to complete right-sided ophthalmoplegia and optic neuropathy (orbital apex-cavernous sinus syndrome). MRI showed right cavernous sinus involvement. 4) Intraocular involvement as manifestation of recurrent disease. 62 y.o. woman who had previous diagnosis of diffuse large B-cell lymphoma 6 years before. Previously treated and doing well until August 2019 when she had a seizure and subsequently complained of decreased vision in the right eye. Exam revealed right eye vitreitis and retinal infiltrates in keeping with lymphomatous involvement. 5) Optic neuropathy in the context of widespread disease subsequently diagnosed as lymphoma. 63 y.o. man: 3 months history of fatigue, leg weakness, weight loss, and leptomeningeal enhancement on MRI. Developed sudden vision loss in the left eye, and there was a nodule compressing the optic nerve, which was being considered for a biopsy but in the meantime, developed bilateral weakness, and numbness in both hands. New MRI showed a mass-like focus of leptomeningeal-dural disease at C6-C7 with significant mass effect on the spinal cord, and resection of this lesion was done instead. Pathology revealed ALK anaplastic large cell lymphoma.

Conclusions: Lymphomas can involve the afferent and efferent visual system. The neuro-ophthalmic manifestations can be isolated or part of a more generalized presentation and this can occur at any time during the course of the disease. This case series emphasizes the ophthalmologist’s role in identifying this condition and the importance of being aware of the potential manifestations.