In January 2005 a 54-year-old Caucasian man was referred to the Ophthalmological Department for bilateral visual loss, severe vitritis, and a significant
cataract in both eyes. His clinical history was significant for HCV
infection. The
uveitis treated with low dose of
steroids and immunosuppressors, yielding a partial remission of the symptoms. One year later he developed a Primary Central Nervous System
Lymphoma. In January 2007 he returned to our department for
cataract surgery. The patient underwent
phacoemulsification of the
cataract in the right eye,
intraocular lens implantation and
intravitreal injections of 4 mg
triamcinolone acetonide. After one month fundus biomicroscopy showed a solid lesion at the posterior pole, consistent with a
retinal relapse of the Primary Central Nervous System
Lymphoma. Restaging investigations were unremarkable and ruled out a disease relapse, and a diagnostic
vitrectomy showed only rare inflammatory cells. In view of the progressive swelling of the
retinal lesions we decided to treat the patient with intravitreal
Methotrexate. Complete remission of the
retinal lesions with
retinal scarring was achieved after 12 months. In May 2008 the patient underwent
phacoemulsification of the
cataract in the left eye and
intraocular lens implantation. A vitreal tap was performed and was positive for rare abnormal cells CD45+, CD20-. Vitreous sampling did not yield enough cells for a diagnosis of monoclonality. No systemic or intravitreal
therapy was performed because of the absence of central nervous system relapses, the small number of atypical cells found in the vitreous sample and the absence of
retinal masses. After three months the patient developed a central nervous system relapse of the
lymphoma and rapidly died.
CONCLUSION: In elderly patients suffering from
uveitis a masquerade syndrome should always be suspected. Vitreous sampling may not yield enough cells for diagnosis and the vitritis may be
steroid-sensitive, at least initially. This makes a differential diagnosis between chronic
uveitis and
malignancy-induced
inflammation very difficult.