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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 131-133

Fine-needle aspiration biopsy along with vitrectomy in the diagnosis of primary intraocular lymphoma - An enhanced diagnostic approach


1 Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai, Tamil Nadu, India
2 Department of Uveitis and Ocular Pathology, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission20-Apr-2021
Date of Acceptance25-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Pukhraj Rishi
Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralya, 18 College Road, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_932_21

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  Abstract 


A 70-year-old lady presented with left eye subretinal mass, diagnosed as posterior uveitis previously. Fine-needle aspiration biopsy via transvitreal route proved to be a minimally invasive and effective diagnostic modality for sample collection with minimal complications and of high diagnostic potential.

Keywords: Fine-needle aspiration biopsy, primary intraocular lymphoma, vitrectomy


How to cite this article:
Iyer VA, Rishi P, Biswas J, Rishi E. Fine-needle aspiration biopsy along with vitrectomy in the diagnosis of primary intraocular lymphoma - An enhanced diagnostic approach. Indian J Ophthalmol Case Rep 2022;2:131-3

How to cite this URL:
Iyer VA, Rishi P, Biswas J, Rishi E. Fine-needle aspiration biopsy along with vitrectomy in the diagnosis of primary intraocular lymphoma - An enhanced diagnostic approach. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 21];2:131-3. Available from: https://www.ijoreports.in/text.asp?2022/2/1/131/334993



Primary intraocular lymphoma (PIOL) is a diffuse, large B-cell lymphoma that masquerades as noninfectious or infectious uveitis, white dot syndromes, or occasionally as other neoplasms such as metastatic cancers.[1] The diagnosis is based on the clinical features, optical coherence tomography (OCT), magnetic resonance imaging (MRI), and fine-needle aspiration biopsy guided by an indirect ophthalmoscope.[2] Fine-needle aspiration biopsy is a minimally invasive procedure with high diagnostic accuracy but is fraught with the drawback of limited cellularity of ophthalmic aspirates[3] and risk of vitreous incarceration in the needle tract.

Hereby, we present a case report of PIOL which presented with vitritis and subretinal mass diagnosed with the help of transvitreal fine-needle aspiration biopsy following vitrectomy.


  Case Report Top


A 70 year old lady presented with bilateral diminution of vision for 5 months. She was diagnosed elsewhere as left eye posterior uveitis with no previous history of ocular trauma or surgery. Her reports revealed mild anemia, raised erythrocyte sedimentation rate (ESR) (39 mm/1 h) and C-reactive protein (1.6 mg/L), normal anticholinesterase enzyme levels, and a negative Mantoux (6 mm) test. The right eye examination was unremarkable with a best-corrected visual acuity (BCVA) of 6/12, N6, and intraocular pressure (IOP) of 10 mmHg and immature cataract. The left eye vision was hand motion. The examination revealed IOP 9 mmHg, quiet anterior chamber, immature age-related cataract, vitreous haze with a large peripapillary, and subretinal mass involving the macula [Figure 1]. The PIOL was suspected. The ultrasound [Figure 2] revealed a diffuse retinochoroidal mass involving the macula, superotemporal and inferotemporal periphery with high surface and moderate internal reflectivity measuring 10 mm circumferentially, 15.7 mm anteroposteriorly, and 4 mm thick. The choroid appeared diffusely thickened. No calcification, shifting fluid, or 'T' sign was noted. The MRI of the brain and orbits revealed irregular, elevated lesions in the left eye posterior choroid. The cerebrospinal fluid (CSF) and bone marrow examinations were normal. A complete systemic staging was done, including computed tomography (CT) scans of the chest, abdomen, and pelvis and bone marrow aspirate and biopsy.
Figure 1: Fundus photograph showing diffuse vitreous haze with a subretinal yellow mass lesion in the peripapillary area

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Figure 2: Left eye ultrasound B scan showing several dot-like vitreous echoes and a retinochoroidal mass with high surface and moderate internal reflectivity. The acoustic hollowing can be misleading to confuse with amelanotic choroidal melanoma

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The patient underwent left eye vitrectomy with choroidal biopsy as follows: 25 G sclerotomies were made; 0.05 mL of undiluted vitreous aspirate sample was collected before starting the infusion. Vitrectomy was performed and posterior vitreous detachment was induced. A 26 G needle mounted on silastic tubing, connected to a 10 mL syringe, was inserted into the choroidal mass and 0.25 mL of the sample was collected via active suction by the assistant. Fluid gas exchange was performed. The sample was immediately transported to the pathology department and processed with the help of cytospin. The postoperative period was uneventful. The fine needle aspiration biopsy (FNAB) [Figure 3] revealed pleomorphic large lymphocytes in a necrotic background, suggestive of PIOL.
Figure 3: Hematoxylin and Eosin staining of choroidal biopsy (X100 magnification) depicting large atypical lymphocytes with pleomorphic nuclei (see arrows) suggestive of intraocular lymphoma. The inset showing the atypical lymphocytes in higher magnification (X400)

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  Discussion Top


PIOL usually presents as vitritis with or without subretinal infiltrates. The subretinal mass being a less common presentation, the role of FNAB in the diagnosis of PIOL is very limited. The vertical height of the mass should be >1.5 mm in order to allow FNAB,[3] which in our case was 4 mm. An undiluted vitreous sample was taken before starting the procedure in order to compare the diagnostic potential with choroidal biopsy. In our technique, we directly entered the mass with a 26 G needle instead of creating a retinotomy with a diathermy needle and then entering the subretinal space for biopsy.[4] The advantage of using a thin bore needle was that the wound was self-sealing and there was no need for a subsequent laser retinopexy as would have been needed in the case of a retinotomy. The disadvantage being a limited amount of specimen was obtained (250 μL) though sufficient for cytological analysis.

Cytopathology of the biopsy specimen confirmed the diagnosis of PIOL in the biopsy specimen, while vitreous aspirate revealed non-specific inflammation. Re-emphasizing the fact that a localized intraocular tumor is likely to have a higher concentration of neoplastic cells than any of the adjacent intraocular fluids.[5] FNAB appears to be less invasive and causes fewer intraoperative and postoperative complications than chorioretinal biopsy.[2],[5],[6],[7]

Fine-needle aspiration biopsy following vitrectomy is an excellent diagnostic modality for the confirmation of intraocular lymphoma. While vitrectomy itself is therapeutic for lymphoma limited to the eye, needle biopsy in the same sitting is minimally invasive with very few complications.

The PIOL is a malignant non-Hodgkin's lymphoma (NHL) which either occurs independently to, or in association with, the primary central nervous system lymphoma (PCNSL).

PIOL is a condition which may be closely mimicked by the common masqueraders such as sarcoidosis, tuberculosis, viral retinitis, and syphilis.[8] The diagnosis requires a high degree of clinical suspicion and ruling out all infectious and noninfectious causes. For the demonstration of malignant lymphoma cells in aqueous fluid, vitreous aspirate, transvitreal retinal, subretinal, or chorioretinal biopsy—a complete diagnostic vitrectomy is the preferred method. Our method serves well in terms of its minimally invasive nature and high yield of malignant lymphoma cells in the aspirate. The aspirate can be subjected to cytology, flow cytometry, immunohistochemistry, molecular analysis, and the cytokines[9] may be used as adjuncts in facilitating the diagnosis.

In a resource-challenged situation with constrained access to advanced flow cytometry, molecular analysis, and immunohistochemistry techniques, a good cytopathological examination by an experienced pathologist can still give a reliable and definitive diagnosis.


  Conculsion Top


This case report points toward the importance of a good history clinical examination, lab investigation, and radiological examination to rule out other infectious and noninfectious differentials before reaching the diagnosis of PIOL. The role of FNAB is pivotal in making a diagnosis of PIOL, especially in resource-challenged situations.

After reaching a correct diagnosis, the appropriate treatment can be employed as the first-line management for patients with concomitant PIOL and PCNSL.[10]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

Esther Sunita Content Editor, Sankara Nethralaya Chennai.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sagoo MS, Mehta H, Swampillai AJ, Cohen VM, Amin SZ, Plowman PN, et al. Primary intraocular lymphoma. Surv Ophthalmol 2014;59:503-16.  Back to cited text no. 1
    
2.
Singh AD, Biscotti CV. Fine-needle aspiration biopsy of ophthalmic tumors. Saudi J Ophthalmol 2012;26:117-23.  Back to cited text no. 2
    
3.
Augsburger JJ, Shields JA. Fine-needle aspiration biopsy of solid intraocular tumors: Indications, instrumentation and techniques. Ophthalmic Surg 1984;15:34-40.  Back to cited text no. 3
    
4.
Levy-Clarke GA, Byrnes GA, Buggage RR, Shen DF, Filie AC, Caruso RC, et al. Primary intraocular lymphoma diagnosed by fine-needle aspiration biopsy of a subretinal lesion. Retina 2001;21:281-4.  Back to cited text no. 4
    
5.
Kvanta A, Seregard S, Kopp ED, All-Ericsson C, Landau I, Berglin L. Choroidal biopsies for intraocular tumors of indeterminate origin. Am J Ophthalmol 2005;140:1002-6.  Back to cited text no. 5
    
6.
Lafaut BA, Hanssens M, Verbraeken H, De Laey JJ. Chorioretinal biopsy in the diagnosis of intraocular lymphoma: A case report. Bull Soc Belge Ophtalmol 1994;252:67-73.  Back to cited text no. 6
    
7.
Cole CJ, Kwan AS, Laidlaw DA, Aylward GW. A new technique of combined retinal and choroidal biopsy. Br J Ophthalmol 2008;92:1357-60.  Back to cited text no. 7
    
8.
Sen HN, Bodaghi B, Hoang PL, Nussenblatt R. Primary intraocular lymphoma: Diagnosis and differential diagnosis. Ocul Immunol Inflamm 2009;17:133-41.  Back to cited text no. 8
    
9.
Jahnke K, Thiel E, Abrey LE, Neuwelt EA, Korfel A. Diagnosis and management of primary intraocular lymphoma: An update. Clin Ophthalmol 2007;1:247-58.  Back to cited text no. 9
    
10.
Kim SK, Chan CC, Wallace DJ. Management of primary intraocular lymphoma. Curr Oncol Rep 2005;7:74-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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