Diagnosis Of Intraocular Lymphoma Research Articles

Цитологические исследования при диагностике увеита. Клинический пример

Purpose. To demonstrate on a clinical example the use of laboratory cytological methods for the differential diagnosis of masquerade syndrome and uveitis. Methods. A clinical example of а 77-year-old patient is presented. She was diagnosed with uveitis and received courses of anti-inflammatory therapy for 6 years without positive dynamics. Further, an assumption was made about the tumor cause of inflammation (primary bilateral intraocular lymphoma), a diagnostic vitrectomy with vitreous sampling for cytological examination was performed. Cytological examination confirmed the diagnosis of lymphoma. Results A patient with uveitis was suspected to have masquerade syndrome. A cytological examination of the vitreous body was performed; as a result, the diagnosis of intraocular lymphoma was unequivocally confirmed. The patient’s examination plan and further treatment were radically revised. Key words: intraocular lymphoma; uveitis; cytological examination.

Highly Sensitive Interleukin Score for Intra-Ocular Lymphoma Diagnosis: Evidence from Analysis of 5-Year Real-Life of Use

Introduction Primary vitreoretinal lymphoma (PVRL) is a rare and aggressive subset of large B-cell lymphoma of immune-privileged sites. It can occur independently or concomitantly to primary central nervous system lymphoma. Symptoms are not specific and can easily be confused with other uveitis. Diagnosis of intra-ocular lymphoma (IOL), including PVRL and secondary lymphoma localization, is based on malignant lymphoid cells identification in vitrectomy(cytology, flow cytometry, molecular analysis). Nevertheless, the fragility of lymphoma cells and low cellularity of samples make diagnosis difficult with these cellular tools. The quantification of interleukin (IL) in intraocular fluids is a promising soluble alternative approach. Based on IL-10 and IL-6 levels, an Interleukine Score for intra-Ocular Lymphoma Diagnosis (ISOLD) designed for aqueous humor (AH) and vitreous was published to guide the diagnosis of IOL (Costopoulos et al, Ophtalmology, 2016). The aim of this work was to evaluate ISOLD performances in real-life practice after five-year of use in a hospital laboratory. Material and methods IL-10 and IL-6 were measured in intra-ocular sample in a single laboratory using the cytometric bead array® kit (BD Biosciences TM) on a FACS Canto II cytometer, with a limit of quantification of 2.5 pg/ml. ISOLD is calculated at diagnosis in AH (AH-ISOLD) or vitreous (V-ISOLD) samples and is associated with a probability of having a large B-cell IOL. This score classifies patients according to two groups: i) reliable zone: ISOLD < -4.6 (<1% probability to have IOL) and ISOLD > +4.6 (>99% probability to have IOL) ; ii) doubtful zone: ISOLD ranging from -4.6 to +4.6 for which the probability and the clinical context have to be considered. All calculated ISOLD from January 2017 to December 2021 were collected. Centers with more than 30 intraocular samples with a calculated ISOLD were contacted to retrieve patients' definitive diagnosis and potential treatments. Results During these 5 years, IL-10 and IL-6 levels have been quantified for 2796 intraocular samples from 70 centers. ISOLD was calculated at diagnosis for 2013 ocular samples. Clinical data were obtained for 1449 samples (1220 AH and 229 vitreous) corresponding to 1243 patients from 13 out of the 18 centers contacted. 9.7% of patients had an IOL, 82.2% had another diagnosis than IOL and 8.1% of patients had no established diagnosis (Figure 1). Considering the 1341 samples with an established diagnosis, 92.7% were in the reliable zone and 7.3% were in the doubtful zone. For the 1128 AH samples, 1050 AH-ISOLD (93.1%) were in the reliable interpretation zone, with a concordant result for 98.6% of them (n=1035 samples) and a discordant result for 1.4% of them (n=15) (Table 1). The sensitivity and specificity were respectively estimated at 90.6% and 99.3% with a positive predictive value (PPV) of 91.7% and a negative predictive value (NPV) of 99.2%. Seventy-eight AH-ISOLD were in doubtful zone including 23 LIO and 55 others diagnoses than IOL. For the 213 vitreous samples, 193 V-ISOLD (90.6%) were in the reliable interpretation zone, with a concordant result for 98.4% of them (n=190 samples) and a discordant result for 1.6% of them (n=3) (Table 1). The sensitivity and specificity were estimated at 97.6% and 99.1%, respectively with a PPV of 98.8% and a NPV of 98.2%. Twenty V-ISOLD were in doubtful zone including 5 LIO and 15 others diagnoses than IOL. Three patients of the 8 who had a false-negative AH-ISOLD had a positive V-ISOLD. For the 17 AH-ISOLD in the doubtful zone, 4 of them had a V-ISOLD concordant with the diagnosis and 2 had an AH-ISOLD in the other eye concordant with the diagnosis. Independently of the sample type, the main cause of false-negative results was administration of corticosteroids prior to sampling and the main causes of false-positive results were infectious diseases (varicella and herpes virus, toxoplasmosis, syphilis). Conclusion This study confirmed on a 5-year period of real life practice that ISOLD, based on IL-10 and IL-6 levels, is a powerful tool to guide the diagnosis towards IOL. In more than 90% of intra-ocular samples, ISOLD was in reliable interpretation zone with very high sensitivity and specificity levels. In case of positive or doubtful AH-ISOLD, a vitrectomy is needed to make the diagnosis. Easy to use, not expansive, this score appears very useful to optimize the diagnostic approach of this rare and aggressive large B-cell lymphoma.

Gene Panels for Intraocular Lymphoma Can Overcome Diagnostic Difficulties and Enable Precision Medicine

Background: Definitive diagnosis of intraocular lymphoma (IOL) is often challenging, at least partially due to limited accessibility to the lesion and the rarity of tumor cells, with pathologically false-negative results reportedly occurring in approximately 30% of cases. Delayed diagnosis is often an important clinical issue, and the average time to diagnosis is approximately 1.5 years.Because of delayed diagnosis, IOLs are often found only after central nervous system (CNS) invasion has occurred, possibly leading to worse treatment outcomes. In this study, we tried to overcome diagnostic difficulties by using gene panel diagnostics of IOL. Furthermore, genetic analysis of IOLs may be able to predict the risk of recurrence.in Japan, a second-generation Bruton's tyrosine kinase (BTK) inhibitor, tirabrutinib, has been approved for the treatment of relapsed/refractory CNS lympoma. Herein, we present a case of IOL and CNS lesion with MYD88 mutation treated with tirabrutinib as part of precision medicine. Methods: We have developed a digital polymerase chain reaction-based system for multiplex gene panel testing of cell-free DNA (cfDNA) obtained from intraocular liquid biopsies (patent number 7149000, 2022/9/30). Our system can detect specific gene mutations in minute cfDNA by amplifying specific gene loci in bubbles, even from an extremely small number of cells. Using this multiplex gene panel testing, we analyzed genetic mutations in nine regions of four genes, MYD88, CD79B, BTG2, and PIM1, using cfDNA obtained from intraocular liquid biopsies. The diagnostic performance of the novel system was evaluated in 86 samlpes of patients with IOL. We also retrospectively analyzed the prognostic potential of the genetic mutations for IOL. Lastly, in the case of CNS lymphoma and IOL, we presented the MYD88 mutation treated with tirabrutinib. Results: Among the four disease-specific genes, the MYD88 mutation was present in 55 of 86 cases (64%), and frequencies of the CD79B, BTG2, and PIM1 mutations were 47%, 38%, and 29%, respectively. At least one of these mutations was found in 83 of the 86 IOL cases examined (97%), making this assay highly sensitive (Fig. 1). The MYD88 mutation was not associated with recurrence in patients with recurrent and refractory CNS lymphoma and IOL. Conversely,patients with the CD79B mutation had high rates of relapse for CNS lymphoma: the 4-year rate of recurrence-free survival was 35%, compared to 79% in patients without the CD79B mutation (p=0.012). Patients with the BTG2 mutation also had high rates of relapse (Fig. 2). Furthermore, we present a case of CNS lynphoma and IOL. By testing IOL gene panel, only MYD88 mutation was detected in the vitreous sample of IOL patient. We have experienced this case in which the second-generation BTK inhibitor,tirabrutinib, was effective not only for central but also for intraocular lesions. Conclusion: Our panel enables rapid and accurate diagnosis of IOL with only a small sample of intraocular liquid. We believe that this multiplex gene panel testing may aid in the diagnosis of IOL in difficult-to-diagnose patients, including those with chronic uveitis, by preventing CNS invasion due to diagnostic delay. Moreover, genetic profiling panels of IOL can help to stratify clinical outcomes.CD79B and BTG2 mutation is a potent predictive marker for relapse. In the clinical setting, we experienced a case of IOL with MYD88 mutation in which tirabrutinib was effective. Potentially, tirabrutinib also penetrates directly into the eye in intraocular lesions. Oral drug, tirabrutinib as eye dripping drug, might be effective as a therapeutic option for IOL and should be assessed in future clinical trials of precision medicine for IOL.

Logistic regression models of cytokines in differentiating vitreoretinal lymphoma from uveitis.

BackgroundVitreoretinal lymphoma (VRL) can commonly masquerade as chronic idiopathic uveitis due to its nonspecific clinical presentation. Thus, its early diagnosis is difficult. In this study, new logistic regression models were used to classify VRL and uveitis. Additionally, the diagnostic performance of interleukin (IL)‐10, the IL‐10/IL‐6, and the Interleukin Score for IntraOcular Lymphoma Diagnosis (ISOLD) are evaluated.MethodsSixty‐nine aqueous humors (AH) (46 VRL, 23 uveitis) and 65 vitreous humors (VH) (49 VRL, 16 uveitis) were collected from a single‐center retrospective cohort. Logistic regression models were conducted based on IL‐6 and IL‐10. The cut‐off values, area under the receiver operating characteristic curve (ROC) curve (AUC), sensitivity and specificity of IL‐10, the IL‐10/IL‐6, the ISOLD, and the models were calculated from the ROC. Furthermore, Spearman's rank correlation analysis was performed to determine cytokine levels in VH and AH.ResultsWe redefined the cut‐off values of IL‐10, the IL‐10/IL‐6, the ISOLD, and the logistic regression models. In AH, the AUC values of IL‐10, ISOLD, IL10/IL6, and the model were 0.91, 0.953, 0.952, and 0.967. In VH, they were 0.93, 0.95, 0.954, and 0.954, respectively. IL‐6 (r = 0.7844) and IL‐10 (r = 0.8506) in AH and VH showed a strong correlation.ConclusionsIL‐6 and IL‐10 levels were introduced into new logistic regression models. The diagnostic efficacy of the models improved compared to the indicators mentioned above among Chinese patients. Additionally, the models could predict the probability of VRL more accurately. A strong correlation of cytokine levels showed the great potential of AH as prioritized auxiliary diagnostic for VRL.

Intraocular lymphoma masquerading as unilateral hypopyon anterior uveitis: a case report

PurposeTo report an unusual case of unilateral anterior segment large B-cell intraocular lymphoma (IOL) presenting as a recurrent hypopyon anterior uveitis.Case presentationA 55-year-old female was referred because of recurrent unilateral anterior hypopyon uveitis with partial response to topical corticosteroid. All of the laboratory tests, review of systems and ocular sampling results were unremarkable. Given a high concern for masquerades syndromes, cytological specimens were obtained 3 times and the last sample showed large B cell lymphoma. First, it appeared confined to the eye and initially responded favorably to local chemotherapy (methotrexate and rituximab) but later went on to develop systemic involvement. CNS lymphoma was detected on the third brain MRI 6 months following ocular involvement. At this time, systemic chemotherapy was started. In the last 18 months’ follow-up, visual acuity was 20/30 in the right eye without posterior segment or fellow eye involvement.ConclusionUnusual presentation of intraocular lymphoma as a unilateral isolated anterior hypopyon uveitis should be kept in mind. This report emphasizes the importance of precise work-ups and multiple ocular biopsies to confirm the diagnosis of intraocular lymphoma.

Comprehensive Laboratory Diagnostic Workup for Patients with Suspected Intraocular Lymphoma including Flow Cytometry, Molecular Genetics and Cytopathology.

Background: Intraocular lymphoma (IOL) presents a real challenge in daily diagnostics. Cyto- and/or histopathology of vitreous body represent the diagnostic cornerstones. Yet, false negative results remain common. Therefore, we analyzed the diagnostic significance of flow cytometry (FC) within the workup algorithm of IOL and compared its sensitivity with the results obtained from routine cytopathology and molecular genetics; Methods: Seven patients undergoing vitrectomy due to suspected IOL were investigated by FC and parallel cytopathology and, if available, digital droplet PCR (ddPCR) for MYD88 L265P; Results: Four out of seven patients were finally diagnosed with IOL. Among the IOL patients, cytopathology confirmed the presence of lymphoma cells in only two cases. In contrast, FC was positive for IOL in all four cases, and FC additionally confirmed the lack of IOL in the remaining patients. In IOL patients diagnosed by FC and with available ddPCR, the diagnosis of IOL was confirmed by the presence of the MYD88 L265P mutation in all three patients; Conclusions: The combination with FC was superior to cytopathology alone in the diagnostic work-up of IOL, and it showed an excellent correlation with ddPCR results. A comprehensive diagnostic panel consisting of cytopathology, FC and molecular genetics should be considered for the work-up of suspected IOL.

Vitreous proteomics, a gateway to improved understanding and stratification of diverse uveitis aetiologies.

PurposeThe vitreous proteome might provide an attractive gateway to discriminate between various uveitis aetiologies and gain novel insights into the underlying pathophysiological processes. Here, we investigated 180 vitreous proteins to discover novel biomarkers and broaden disease insights by comparing (1). primary vitreoretinal lymphoma ((P)VRL) versus other aetiologies, (2). sarcoid uveitis versus tuberculosis (TB)‐associated uveitis and (3). granulomatous (sarcoid and TB) uveitis versus other aetiologies.MethodsVitreous protein levels were determined by proximity extension assay in 47 patients with intraocular inflammation and a prestudy diagnosis (cohort 1; training) and 22 patients with a blinded diagnosis (cohort 2; validation). Differentially expressed proteins identified by t‐tests on cohort 1 were used to calculate Youden’s indices. Pathway and network analysis was performed by ingenuity pathway analysis. A random forest classifier was trained to predict the diagnosis of blinded patients.ResultsFor (P)VRL stratification, the previously reported combined diagnostic value of IL‐10 and IL‐6 was confirmed. Additionally, CD70 was identified as potential novel marker for (P)VRL. However, the classifier trained on the entire cohort (cohort 1 and 2) relied primarily on the interleukin score for intraocular lymphoma diagnosis (ISOLD) or IL‐10/IL‐6 ratio and only showed a supportive role for CD70. Furthermore, sarcoid uveitis displayed increased levels of vitreous CCL17 as compared to TB‐associated uveitis.ConclusionWe underline the previously reported value of the ISOLD and the IL‐10/IL‐6 ratio for (P)VRL identification and present CD70 as a potentially valuable target for (P)VRL stratification. Finally, we also show that increased CCL17 levels might help to distinguish sarcoid uveitis from TB‐associated uveitis.

The diagnostic value of IL-10 and IL-6 level in vitreous fluid and aqueous humor for vitreoretinal lymphoma

BackgroundVitreoretinal lymphoma (VRL) is a subtype of central lymphoma, which at present is hard to diagnose. The gold standard of VRL diagnosis is vitreous cytology, but the vitreous specimen needs to be obtained by the invasive surgery of vitrectomy. Aqueous humor is easier to obtain, has better stability, and has a lower operating risk than vitreous specimens. MethodsWe studied the diagnostic value of interleukin 10 (IL-10), IL-10/ IL-6 ratio and interleukin score for intraocular lymphoma diagnosis (ISOLD) in both vitreous and aqueous humor for vitreoretinal lymphoma, to determine if aqueous humor could be used to assist in the diagnosis of vitreoretinal lymphoma (VRL) by detecting IL-6 and IL-10. ResultsThe area under ROC curve (AUC) of vitreous fluid IL-10, IL-10/IL-6 ratio and ISOLD at the diagnosis of VRL diagnosis were 93.5%, 93.6% and 93.8%, respectively. The AUC of the aqueous humor IL-10, IL-10/IL-6 and ISOLD for VRL diagnosis were 83.8%, 72.8% and 85.9%, respectively. ConclusionsAqueous humor can thus replace vitreous humor as a potential sample type for the diagnosis of intraocular lymphoma.

Discrimination of dissociated lymphoma cells from leukocytes by Raman spectroscopy

Diagnosis of intraocular lymphoma is difficult. Among the hurdles in the diagnosis are the variety of reactive inflammatory and ischemic changes among intraocular lymphoma patients. Thus, a novel diagnostic method is desired such that lymphoma cells can be distinguished by the signals intrinsic to the cells, not by those from the surrounding tissues with reactive changes. Raman spectroscopy is a technique that can detect intrinsic signals from each cell. Therefore, Raman spectroscopy is a good candidate for an intraocular evaluation technology that could contribute to improve the diagnosis of intraocular lymphoma. In this study, we tested whether the intrinsic Raman signals from malignant lymphoma cells, in the absence of surrounding tissue, were sufficient for the discrimination of malignant lymphoma cells from leukocytes. We acquired spectra from dissociated lymphoma cells, along with spectra from normal B cells and other leukocytes involved in intraocular inflammatory diseases. We analysed the spectra using principal component analyses and quadratic discriminant analyses. We found that Raman spectra from dissociated cells without confounding tissues showed high discriminating ability, regardless of the variation due to day-to-day differences and donor differences. The present study demonstrates the possible effectiveness of Raman spectroscopy as a tool for intraocular evaluation.

Logistic Regression Classification of Primary Vitreoretinal Lymphoma versus Uveitis by Interleukin 6 and Interleukin 10 Levels

To assess the diagnostic performance and generalizability of logistic regression in classifying primary vitreoretinal lymphoma (PVRL) versus uveitis from intraocular cytokine levels in a single-center retrospective cohort, comparing a logistic regression model and previously published Interleukin Score for Intraocular Lymphoma Diagnosis (ISOLD) scores against the interleukin 10 (IL-10)-to-interleukin 6 (IL-6) ratio. Retrospective cohort study. Patient histories, pathology reports, and intraocular cytokine levels from 2339 patient entries in the National Eye Institute Histopathology Core database. Patient diagnoses of PVRL versus uveitis and associated aqueous or vitreous IL-6 and IL-10 levels were collected retrospectively. From these data, cytokine levels were compared between diagnoses with the Mann-Whitney U test. A logistic regression model was trained to classify PVRL versus uveitis from aqueous and vitreous IL-6 and IL-10 samples and compared with ISOLD scores and IL-10-to-IL-6 ratios. Area under the receiver operating characteristic curve (AUC) for each classifier and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at the optimal cutoff (maximal Youden index) for each classifier. Seventy-seven lymphoma patients (10 aqueous samples, 67 vitreous samples) and 84 uveitis patients (19 aqueous samples, 65 vitreous samples) treated between October 5, 1999, and September 16, 2015, were included. Interleukin 6 levels were higher and IL-10 levels were lower in uveitis patients compared with lymphoma patients (P < 0.01). For vitreous samples, the logistic regression model, ISOLD score, and IL-10-to-IL-6 ratio achieved AUCs of 98.3%, 97.7%, and 96.3%, respectively. Sensitivity, specificity, PPV, and NPV at the optimal cutoffs for each classifier were 94.2%, 96.9%, 97%, and 94% for the logistic regression model; 92.7%, 100%, 100%, and 92.9% for the ISOLD score; and 94.2%, 95.3%, 95.6%, and 93.9% for the IL-10-to-IL-6 ratio. All models achieved complete separation between uveitis and lymphoma in the aqueous data set. The accuracy of the logistic regression model and generalizability of the ISOLD score to an independent patient cohort suggest that intraocular cytokine analysis by logistic regression may be a promising adjunct to cytopathologic analysis, the gold standard, for the early diagnosis of primary vitreoretinal lymphoma. Further validation studies are merited.

Epidemiology and clinical features of intraocular lymphoma in Singapore.

Intraocular lymphoma is rare. There are very few studies on intraocular lymphoma published from Asian countries. To report our case series of intraocular lymphoma patients from a tertiary eye centre in Singapore. Nine patients with intraocular lymphoma managed between January 2005 and December 2014 were identified from Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) database. Demographic characteristics, clinical presentation, investigations performed and outcomes recorded. There were almost equal distribution between males (four patients) and females (five patients) with mean age of presentation was 60.3 years. Five patients had bilateral involvement and vitreo-retina was the most common site of infiltration. All of our patients had central nervous system involvement although four of them had presented with ocular manifestations initially. Anterior chamber fluid cytology, as a less invasive alternative to vitreous analysis was proven to be useful. The time from ocular presentation to diagnosis of ocular lymphoma was variable; from one day to 18 months. Mortality in our study group was 55% with death occurring 1 month to 8 years from diagnosis of intraocular lymphoma. Intraocular lymphoma is a masquerade syndrome that mimics chronicuveitis and poses a diagnostic challenge. The diagnosis is often delayed and despite the eventual diagnosis, the disease prognosis is poor even with aggressive treatment.

Bilateral Severe Vitritis, an intraocular recurrence of B cell lymphoma: A case report.

Purpose: To report a case of bilateral vitritis originated from Primary Central Nervous System Lymphoma. Diagnosis was made from a careful history taking and confirmed with vitrectomy. Case report: 65-year-old Vietnamese male had one month of progressive blurred vision in both eyes without other eye complaint. History revealed that about one year previously, he was diagnosed with primary diffuse large B cell lymphoma. He was treated with chemotherapy of Methotrexate 3.5 g/m2 and cytarabine 2 mg/m2, and a whole brain radiation therapy. There was a complete remission after the therapy. Fundus of both eyes was partly obscured by cells mainly in the posterior vitreous. Sequential bilateral vitrectomies were done on 5/1/17 and 7/17/17 without complication. The vitreous sample from the first eye having vitrectomy was sent for study which demonstrated large B cell lymphoma. Post-operative vision improved to 20/25 both eye without the complaint of hazy vision. Conclusion: Good history taking assisted in the diagnosis of intraocular lymphoma in this case with bilateral vitritis. However, bilateral vitrectomy restored the vision and further confirmed the diagnosis of lymphoma for future follow up care.

Interleukins in the Diagnosis of Intraocular Lymphoma: Do We Still Need Histologic Confirmation?

Primary vitreoretinal lymphoma (PVRL, also called primary intraocular lymphoma) is a rare disease with an estimated incidence of about 380/year in the United States.1 Men are slightly more often affected than women. The incidence increases with age and PVRL is extremely rare in patients under the ag

Cytopathologic findings of cell block materials from the vitreous: Diagnostic distinction between intraocular lymphoma and non-lymphomatous diseases.

Intraocular lymphoma is a rare neoplasm that occurs only in the eyes and/or central nervous system. Diagnosis of intraocular lymphoma is difficult because its clinical manifestations mimic chronic uveitis. Pathological examination of the vitreous is one of the main diagnostic tools for intraocular lymphoma, but this is challenging due to the sparse cellularity and specimen degeneration. Here, we reviewed 33 cell block preparations from vitreous perfusion fluid in order to examine the significance of cytopathological findings for differential diagnosis using vitreous samples. The cases comprised 12 intraocular lymphomas and 21 non-lymphomatous diseases. Cytologically, vitreous samples from non-lymphoma cases showed lower cellularity than the lymphoma cases. Whereas vitreous material from cases with infectious endophthalmitis showed prominent neutrophilic infiltration, material from sarcoidosis cases showed infiltration of small lymphoid cells, especially CD4-positive T cells. On the other hand, lymphoma cases showed higher cellularity, with large, irregular and atypical lymphoid cells, frequent necrotic cells in the background, and less pronounced neutrophil infiltration. Immunocytochemically, 11 of the 12 lymphoma cases were of the B-cell phenotype and the remaining case was of the T/NK-cell phenotype. In conclusion, careful cytopathological examination or immunocytochemistry of vitreous material facilitates appropriate diagnosis of intraocular lymphoma.

Problems in the diagnosis of intraocular lymphoma

SummaryIntraocular lymphoma means different entities. Primary vitreoretinal lymphoma can mascarade a chronic uveitis. This lymphoma is a subset of primary cerebral lymphoma. The disease is a B cell non hodgking lymphoma, aggressive, with a survival rate of less than 2 years after the occurrence of cerebral localization. Clinical examination, fluorescein angiography, OCT can be highly suggestive combined with resistance to corticosteroids. Diagnosis is based on cytokines levels (IL10/IL6) in aqueous humor or vitreous and diagnostic vitrectomy. Uveal localization of MALT lymphoma is rare and much more difficult to diagnose. This affection can mimic choroidal metastasis or a posterior scleritis or achromic uveal melanoma. The diagnosis can be suspected clinically (unpainfull choroidal thickening), hypoechogenic choroidal infiltration, typical aspect on ocular MRI. The diagnosis is based on episcleral, or choroidal biopsy.

The Role of Chorioretinal Biopsy in the Diagnosis of Intraocular Lymphoma

To assess the clinical usefulness of chorioretinal biopsy in establishing a definitive diagnosis in intraocular lymphomas. Retrospective, noncomparative, consecutive diagnostic case series. setting: Moorfields Eye Hospital, London, United Kingdom. Twenty-nine consecutive patients presenting with severe uveitis that required an intraocular biopsy where underlying lymphoma was suspected. A retrospective review of a 15-year period (1999-2014) was undertaken of all patients that have undergone chorioretinal biopsy for suspected lymphoma at Moorfields Eye Hospital, London, United Kingdom. Patients were identified on the hospital's computerized database. Effectiveness of chorioretinal biopsy in establishing a definitive diagnosis or in excluding malignancy. A specific histologic diagnosis was made in 17 cases (59%) while in 9 cases the biopsy combined with clinical data was effective in excluding malignancy. In the 3 remaining cases, no specific diagnosis was made. No intraoperative complications were reported. Postoperative complications other than cataract included 2 vitreous hemorrhages and 2 retinal detachments. Of the 17 cases with a histologic diagnosis, 15 were obtained in eyes with marked vitritis, as opposed to 2 with minimal vitritis. Chorioretinal biopsy provided a definitive diagnosis of lymphoma in 59% of cases and assisted in exclusion of a further 31% in this series. The level of vitritis appears to act as a strong index of likelihood in achieving a definitive histologic diagnosis.

Transretinal Biopsy of Intraocular Lymphoma

Intraocular lymphoma is in most cases a diagnostic challenge. Gold standard is a diagnostic vitrectomy. Vitreous biopsy and transretinal biopsies are therefore employed. A retrospective analysis was undertaken of all cases of cytological or histological proven intraocular lymphoma between 2002 and the beginning of 2015 in our clinic. The diagnosis of intraocular lymphoma could be established in 16 cases by cytological or histological analysis. Six patients had previously been treated with steroids in the assumption of uveitis. Five of 16 patients had a systemic or CNS lymphoma in their history. The diagnosis of intraocular lymphoma could be made on the basis of a vitreous biopsy in only in 3 cases. In 7 cases an additional vitrectomy with transretinal biopsy was needed. In 1 case a transretinal biopsy was performed initially and in 1 case a re-transretinal biopsy was needed to establish the diagnosis. Two patients underwent iris biopsy to diagnose a secondary metastatic intraocular lymphoma. One amaurotic eye was diagnosed with intraocular lymphoma after enucleation. Due to the high relevance for the diagnosis intraocular lymphoma, when a vitreous biopsy was non-informative, a transretinal biopsy should always be considered in cases of retinal or subretinal involvement.

Improving the cytological diagnosis of intraocular lymphoma from vitreous fluid.

To improve the cytological diagnosis of retinal lymphoma on vitreous fluid using improved cell collection and systematic analyses. Since October 2010, we have developed and optimized in our department a method with which to perform the diagnosis of retinal lymphoma. The vitreous sample was collected in a tube containing RPMI-1640 medium, decomplemented fetal bovine serum, and gentamicin. The transport and technical steps were performed at 4°C. Systematically, cytological examination with May-Grünwald-Giemsa staining and immunocytochemistry (mainly anti-CD3, anti-CD20 and anti-CD68 antibodies) were performed on cytospins. Whenever possible, determination of B-cell clonality, flow cytometry and determination of the interleukin (IL)-10/IL-6 ratio were performed. From October 2010 to June 2013, with this optimized protocol, 38 vitreous cytological samples from 32 patients were analysed, and a final diagnosis was possible, avoiding a biopsy, in all cases except one. The preservation of vitreous fluid cells on culture medium led to the diagnosis of retinal lymphoma in 10 of 12 cases, and exclusion of this diagnosis in 26 cases. This protocol may be applied even when the delay in shipping from the surgery to the pathology departments exceeds 1h.

Case Report: Intraocular Non-Hodgkin Lymphoma

Purpose: Primary intraocular lymphoma is a primary central nervous system lymphoma in which lymphoma cells invade the retina, vitreous, or optic nerve head without concomitant central nervous system involvement. The aim of this presentation is to report a case of primary intraocular non-Hodgkin lymphoma. Methods: The authors present a case report of a 77 years-old female with painless decreased in visual acuity and floaters. Ophthalmic examination, Static computerized Perimetry, Spectral-Domain Optical Coherence Tomography, angiography, laboratory study, lumbar puncture, computed tomography scan and magnetic resonance imaging were performed. Results: On examination, best corrected visual acuity was 20/25 in the right eye and 30/60 in the left eye. Slip lamp examination revealed anterior chamber reaction and fundoscopy showed vitritis, optic disc edema, macular edema and vasculitis in left eye. After three months of follow-up, the patient’s best corrected visual acuity decreased to 20/60 in right eye and light perception in left eye. Fundoscopy revealed vitritis, optic disc edema, macular edema and vasculitis in both eyes. A granular pattern, leakage from retinal vessels and optic disc were observed in fluorescein angiography. Infectious and inflammatory etiologies were excluded. Pars plana vitrectomy and retinal biopsy were performed in left eye. Cytology evaluation revealed atypical lymphoid cells with large nuclei, prominent nucleoli and basophilic cytoplasm, and confirmed the diagnosis of intraocular lymphoma. Conclusion: Intraocular Lymphomas are rare malignancies that display a wide array of clinical manifestation, therefore diagnosis can be challenging. It requires a high degree of clinical suspicion and differential diagnosis includes infectious and non-infectious etiologies.

Intravitreal injection of anti-VEGF and diagnosis of primary intraocular central nervous system lymphoma

We report a case of primary intraocular central nervous system (CNS) lymphoma in a patient previously treated with intravitreal anti-vascular endothelial growth factor (VEGF) injections for age-related macular degeneration (AMD). An 88-year-old woman, with past medical history significant for bilateral age-related macular degeneration (AMD) treated with intravitreal ranibizumab injections for 1 year, was referred to our department for bilateral vitritis diagnosed 10 days after the last anti-VEGF injection. A complete uveitis work-up including aqueous humour analysis, brain MRI and vitreous biopsy enabled us to confirm the diagnosis of primary intraocular CNS lymphoma. To the best of our knowledge, this is the first report of the diagnosis of primary intraocular CNS lymphoma in a patient treated with anti-VEGF for AMD. The differential diagnosis of vitritis in elderly patients is relatively broad. Endophthalmitis and uveitis have been described after anti-VEGF injections. In such a situation, there is actually a risk of missing the diagnosis of intraocular lymphoma in the mistaken belief that the observed vitritis may be a reaction to administered anti-VEGFs. If no direct time-relationship with the anti-VEGF injections can be found, a classic vitritis work-up should be performed. Our observation suggests that ranibizumab, at the dosage used for AMD, does not impede the spread of CNS lymphoma in the eye nor interfere with cytological diagnosis.