Bilateral Optic Nerve Infiltration as an Initial Site of Relapse of Acute Lymphoblastic Leukemia in Remission

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CentralNervous System (CNS) relapse in Acute Lymphoblastic Leukemia (ALL) is in a phase where the incidence is expected to decrease due to advent of better systemic chemotherapy CNS prophylaxis via both chemo and radiotherapy, but the fact that the life span of patients have significantly increased compared to yester years contributes to increased incidence. Cases after complete systemic remission presenting with isolated bilateral optic nerve relapse is rarely reported.

An18 year old male, presented with fever 15 days, with swelling in neck both sides. Clinical examination showed multiple, palpable bilateral neck nodes, just palpable hepatomegaly. The hemogram showed elevated total count 18250, with 20% lymphoblasts. The bone marrow examination and flow cytometry confirmed a B-cell ALL. CSF cytology was negative at baseline. The patient was started on MCP 841 protocol, was in remission after induction. There were few episodes of febrile neutropenia during the course of treatment, but was uneventful. In the second Maintenance phase (M2), the patient presented to the OPD with c/o progressive dimness of vision since 1 week. There was no history of loss of consciousness, seizures, disorientation, headache, trauma to eye, diplopia or pain in the eyes. On examination the patient was conscious and oriented, vitals stable. The CNS examination was normal except the optic nerve. The ophthalmic examination is as follows: Left eye: Optic disc atrophy present, generalized oedema, Vascular sheath thickening and tortuosity, superficial flame shaped haemorrhage. Right eye: Vascular sheathing present, generalized oedema present, foveal reflexes dull, vitreous, macula and retinal vessels- normal.