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Rohan Bir Singh, Parul Ichhpujani, Sahil Thakur; OPTIC NERVE LYMPHOMA: ADDRESSING LIMITATIONS OF AN ACTIVE INTERVENTION. Invest. Ophthalmol. Vis. Sci. 2017;58(8):1801.
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© ARVO (1962-2015); The Authors (2016-present)
A case of refractory optic nerve lymphoma in a CHOP treated NHL (Non Hodgkin Lymphoma) & B-cell Type IV(Ann Arbor Staging).
A 51-year-old female diagnosed with NHL Type IV presented to the OPD with decreased vision OS for past 2 months.She had history of fractured Right Femoral Head 1 year back,for which she underwent Prosthetic Hip replacement & bone biopsy revealed NHL(CD20+).She subsequently completed 8 cycles of CHOP regimen 2 months ago.On examination, Vision in OD was 20/20 & OS has FC1m with RAPD +.The adnexa,EOM,anterior & posterior segment examination was essentially normal OU.On MRI focal areas of thickening & signal change were noted in the intracanalicular segment of left optic nerve approx.11mm(6.5mm thick).On T2 sequence,multiple sclerosed skull metastasis after CHOP regimen were noted.HVF 30-2 revealed peripheral field loss in OD with enlargement of blind spot.Oncology consult was sought,watchful waiting was advised keeping in mind the refractory metastasis,risk of toxicity with additional chemotherapy & poor prognosis associated with the spread to the optic nerve.Bendamustine & Adalimumab were considered as reserve drugs,but the patient couldn't afford further therapy.
The patient underwent repeat imaging, which showed bilateral optic nerve involvement with several newer metastasis in skull. Visual acuity reduced to 20/120 in OD and PL negative in OS.Visual field constriction was noted on subsequent visits in right eye with compromised auditory function.The patient’s general physical condition also deteriorated rapidly & she became non-ambulatory after a month of optic nerve involvement.
The uncommon nature of presentation of the optic neuropathy,after completion of chemotherapy & dilemma for additional chemotherapy makes this case unique.In cases with extremely poor prognosis,unnecessary treatment puts additional strain both financially & psychologically on the patient and their family. Thus focus on hospice care, family counselling & most importantly taking the call to not treat is a crucial component of everyday clinical practice,the ethics of this decision are yet to be suitably addressed by literature.
This is an abstract that was submitted for the 2017 ARVO Annual Meeting, held in Baltimore, MD, May 7-11, 2017.
Contrast enhanced MRI at T1 with focal area of thickening,signal change & enhancement in the intracanalicular segment of optic nerve approx.11mm(6.5mm thick)
Contrast enhanced MRI at T2 showing multiple sclerosed skull metastasis post CHOP.
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