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JAMA Ophthalmology Clinical Challenge
December 5, 2019

Acute Promyelocytic Leukemia With Sudden Vision Loss

Author Affiliations
  • 1Los Angeles County and University of Southern California Medical Center, University of Southern California Roski Eye Insitute, Department of Ophthalmology, University of Southern California, Los Angeles
JAMA Ophthalmol. 2020;138(2):206-207. doi:10.1001/jamaophthalmol.2019.4838

A 51-year-old man diagnosed as having acute promyelocytic leukemia, undergoing induction therapy with all-trans-retinoic acid (ATRA) and arsenic trioxide that were started 2 weeks prior, presented with sudden loss of vision. Hospital course was complicated by neutropenic fever, receiving cefepime, acyclovir, vancomycin, and voriconazole for prophylaxis. Laboratory test results were remarkable for pancytopenia. On initial examination, his visual acuity was count fingers at 3 ft in both eyes. Intraocular pressures were 10 mm Hg OD and 11 mm Hg OS. Pupils were round and reactive without a relative afferent pupillary defect. Color plates were 1 of 8 OU, with 50% brightness desaturation in the right eye and no red desaturation. Extraocular movements were full. Slitlamp examination was negative for any signs of inflammation. Dilated fundus examination demonstrated bilateral choroidal effusions with diffuse serous retinal detachments (RD) involving the macula without vitritis as well as white centered intraretinal hemorrhages along peripapillary and superior and inferior arcade distributions in both eyes (Figure, A). Optical coherence tomography demonstrated irregular inner retinal surface and subretinal fluid with septae with loss of the ellipsoid zone (Figure, B). Review of systems was positive for fever, tachycardia, odynophagia, productive cough with wheezing, and marked peripheral edema in upper extremities and negative for headache, nausea, vomiting, dysacusis, meningismus, or skin changes.

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