OSLI Retina

September 2018

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732 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina The Cutting Edge Surgical video section with expert commentary Albini et al. show a fascinating video illustrat- ing a unique finding – a nearly opaque poste- rior capsular plaque that developed in the eye of a pseudophakic woman who, several years previously, underwent a diag- nostic vitrectomy in the same eye for suspected intraocular lymphoma. The earlier biopsy and brain MRI were negative for malignancy. This capsular biopsy was positive for B-cell lymphoma, and repeat MRI showed new central nervous system (CNS) lesions consis- tent with CNS lymphoma. Although the vitre- ous, subretinal space, sub-retinal pigment epi- thelium (RPE) space, and optic nerve are known sites for intraocular lymphoma cells to accumu- late, the posterior capsule is highly unusual. An initial negative vitreous biopsy in the setting of intraocular lymphoma is not unusu- al. Persistence by the ophthalmologist in the pursuit of the diagnosis of primary intraocular lymphoma is often necessary. Multimodal im- aging consisting of fluorescein angiography and fundus autofluorescence looking for "leopard spots" and subtle arterial leakage, as well as op- tical coherence tomography to detect subretinal and sub-RPE abnormalities, can be helpful in cases where the fundus appears normal. Other confirmatory studies may include systemic eval- uation, neuroimaging, lumbar puncture, and multiple sampling of intraocular tissue. This video illustrates several important points: 1) Use of a 6-mm cannula when the view is suspect; 2) confirmation of the presence of the cannula in the vitreous cavity prior to beginning infusion; 3) obtaining an undiluted specimen by the infusion of air as opposed to saline to main- tain intraocular pressure while not diluting the specimen; and 4) use of small-gauge vitrectomy instrumentation to obtain a cytologic specimen. Since cytology remains the best way to diag- nose intraocular lymphoma, proper handling of the biopsy specimen is critical. Discussing these details with an ocular pathologist prior to the bi- opsy is recommended. This case also illustrates that using small-gauge vitrectomy instrumenta- tion does not result in untoward surgical trauma on the cells as some feared initially with the ad- vent of the smaller port cutters and higher cut- ting rates. In summary, primary vitreoretinal lym- phoma is the ultimate cause of the masquerade syndrome and should be kept in mind as a po- tential diagnosis in the proper clinical setting, even when prior vitreous biopsies are negative. Persistence in obtaining the correct diagnosis is necessary. Although highly unusual, this case illustrates that lymphoma cells can accumulate as a posterior capsular plaque in the setting of a pseudophakic, prior vitrectomized eye. Jay S. Duker, MD New England Eye Center at Tufts Medical Center Boston, MA Jay S. Duker, MD Primary Vitreoretinal Lymphoma Presenting as a Posterior Capsule Plaque by Rehan M. Hussain, MD; Robert B. Garoon, MD; Sander R. Dubovy, MD; and Thomas A. Albini, MD ABSTRACT: Primary vitreoretinal lymphoma (PVRL) can be a diagnostic challenge and commonly presents as a partially steroid-responsive vitritis or as subreti- nal cream-colored infiltrates. The authors present a patient with PVRL who initially presented with bilat- eral vitritis; however, after two non-diagnostic vitrec- tomy specimens and two unremarkable brain MRIs, she was lost to follow-up. She presented 2.5 years lat- er with a white plaque on the posterior capsule of her left intraocular lens, though the vitreous cavity was free of infiltrate. Repeat biopsy revealed diffuse large B-cell lymphoma, and brain MRI demonstrated an enhancing lesion of the cerebellum, consistent with primary central nervous system lymphoma.

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