Infiltrative Optic Neuropathy in Acute Lymphoblastic Leukemia with Negative Bone Marrow Biopsy

A 46-year-old woman with a history of acute lymphocytic leukemia (ALL) in remission and recent negative bone marrow biopsy was examined for right eye discomfort while inpatient for pancytopenia and cytomegalovirus enteritis. Initial exam showed 20/25 vision in both eyes, mild blurring of the nasal disc margin in the right eye, and a cotton wool spot in the left eye. MRI revealed enlargement and enhancement of the right optic nerve. Five days later, she developed blurry vision and transient positional vision loss in the right eye, with visual acuity declining to 20/40. Repeat exam showed grade 2 optic disc edema with flame hemorrhages, an infiltrative lesion in the right eye. Lumbar puncture revealed 94% blast cells. She was started on corticosteroids, and an Ommaya reservoir was placed for intrathecal chemotherapy. Ophthalmologists should suspect leukemic optic nerve infiltration in ALL patients with optic nerve edema, even after negative bone marrow biopsies.