Optic Nerve Infiltration in Adult Acute Lymphoblastic Leukaemia (ALL)

Abstract

Acute lymphoblastic leukemia (ALL) is the most common childhood leukaemia. It is a malignant neoplasm caused by the proliferation of poorly differentiated precursors of the lymphoid cells. It is relatively uncommon in adult. In adult ALL, central nervous system (CNS) involvement is associated with poor prognosis. The incidence of CNS involvement has been reported between 7% and 15 %.  We report a case of optic nerve infiltration in ALL in a 49 years old gentleman. He was diagnosed with precursor-B ALL. He was treated with chemotherapy and CNS prophylactic regime. He presented with sudden left eye loss of vision for one-day duration with history of right eye inferior visual field loss for the past three months. His visual acuity was no perception to light on the left eye and 6/9 on the right eye. There was marked left relative afferent pupillary defect. The right eye showed decreased in optic nerve function with inferior visual field defect. Anterior segment examination was unremarkable in both eyes. Left optic disc appeared normal but the right optic disc was pale.  Blood investigation showed no sign of infection or haemoconcentration. Cerebral spinal fluids examination revealed abundant of white cells and blast cells. Magnetic resonant imaging showed bilateral optic nerve enhancement suggesting of bilateral optic nerves infiltration. He was started on a new regime of chemotherapy followed by cranial radiotherapy. Unfortunately, he succumbed to death due to septicaemia. There are variations in clinical presentation of optic nerve infiltration in leukaemic patients. Normal appearance of optic disc may not exclude the possibility of infiltration by malignancy. Assessment of the optic nerve function and imaging is helpful for the detection of leukaemic infiltration. Early detection of optic nerve infiltration is important for initiation or change of therapy to prevent mortality.