A 69-year-old male was referred with left eye pain, redness, and poor vision 3 days after uncomplicated phacoemulsification and posterior chamber intraocular lens implantation. On presentation, the best corrected visual acuity (BCVA) values were 20/32 and 20/800 in the right and left eyes, respectively. There was no relative afferent pupillary defect. The findings of the slit-lamp examination of the left eye were microcystic corneal edema, localized Descemetʼs detachment, and 3+ cell and fibrin in the anterior chamber.
Posterior segment examination disclosed vitritis, optic disk swelling, vascular sheathing, small intraretinal hemorrhages and patches of retinitis in the superior quadrant, and pigmentary changes at the macula in the left eye. The right eye appeared normal except for senile cataract and small Drusen-like lesions (Figure 1) .Firstly, the clinical diagnosis of acute retinal necrosis was made. Therefore, undiluted vitreous sampling was prepared for polymerase chain reaction (PCR) evaluation of infectious etiologies, including herpes simplex virus (HSV), cytomegalovirus (CMV), varicella-zoster virus (VZV), EBV, and Toxoplasma. Moreover, vitreous and aqueous humor samples for smear and culture for bacterial infection with a probable diagnosis of acute postoperative endophthalmitis were also acquired.
The patient was treated with intravenous acyclovir (10 mg/kg/every 8 h), intravitreal ganciclovir (twice a week), and systemic oral prednisolone (50 mg/day). The retinitis and inflammation were partially improved following the treatment. After 10 days of treatment, systemic intravenous acyclovir was replaced by valacyclovir (1 g/every 8 h) with an incomplete response to the treatment.
A month later, the patient complained of decreasing vision and vitreous reaction accompanied by retinal vasculitis. In addition, punctate Drusen-like subretinal infiltration foci were observed in the examination of the right eye. The aforementioned treatment was continued and vitreous sampling of the right eye was performed for PCR and cytological evaluation with the suspicion of masquerade syndrome, especially PIOL.
Spectral-domain optical coherence tomography (SD-OCT) revealed multiple tiny Drusen-like retinal pigmented epithelium elevation in the right eye and retinal edema, hyperreflectivity of inner retina at retinitis area, and increased central macular thickness in the left eye (Figure 2). Fluorescein angiography was not provided due to an allergic reaction. The FAF showed numerous hyperautofluorescent dots scattered at the posterior pole of the right eye and stippled mixed hyper- and hypoautofluorescent dots (leopard pattern) at the posterior pole and vitreous opacity corresponding to vitritis in the left eye (Figure 1).
In the analysis of the vitreous sample, the results PCR for VZV, HSV, CMV, and Toxoplasma were all negative, except for EBV deoxyribonucleic acid (DNA) in both eyes. In addition, the histopathological examination of the vitreous sample showed malignant lymphocyte cells compatible with the diagnosis of B-cell lymphoma with positive CD20 and CD19 markers. Systemic workups, including brain magnetic resonance imaging (MRI) with contrast enhancement and ultrasound of the pelvic, abdomen, and cervical lymph node chain, and oncologist consultation revealed no pathologic findings. As a result, with the diagnosis of PIOL, local intraocular chemotherapy (monthly intravitreal rituximab and methotrexate twice a week for 1 month, weekly for next month, and then monthly) was initiated. Clinical response was good, and BCVA increased to 20/32 and 20/50 in the right and left eyes, respectively.
After 4 months, symptoms of cognitive and behavioral impairment appeared. However, the second brain MRI was also normal, the protein level of cerebrospinal fluid (CSF) analysis was high. The cytological evaluation of the CSF sample revealed malignant lymphocyte cells. Therefore, with the diagnosis of CNS lymphoma, systemic chemotherapy was also initiated. The patient expired during systemic chemotherapy.