Visual Acuity Loss in a Healthy Man -JAMA Clinical Case
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A healthy man in his 60s presented with a 4-month history of blurred vision in his left eye. On examination, his visual acuity was 20/20 OD and 20/40 OS. Intraocular pressures were normal in each eye. Anterior segment and fundus examination results were normal in the right eye. In the left eye, the media were clear, and there were multiple patchy, yellow choroidal lesions with obliteration of the normal choroidal vasculature throughout the entire fundus. Ocular ultrasonography revealed diffuse ciliochoroidal thickening measuring 2.9 mm in elevation. Optical coherence tomography disclosed generalized, undulating choroidal infiltration in a seasick pattern, so to speak, given its resemblance to a stormy ocean surface, with overlying draping of the retina in the foveal region.

A relook at the anterior segment in the left eye revealed a faint conjunctival thickening at the limbus suggestive of lymphoid tumor. Incisional biopsy of the epibulbar lesion revealed sheetlike infiltration of small monomorphic lymphocytes with irregular nuclear contours and Dutcher bodies.The findings on the relook at the anterior segment were suggestive of a choroidal lymphoid process. Themorphology found on incisional biopsy with immunohistochemistry was compatible with mature small B-cell lymphoma, including extranodal marginal-zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT), with prominent plasmacytic differentiation or lymphoplasmacytic lymphoma.

External beam radiotherapy was chosen, and to minimize radiation adverse effects from standard-dose therapy (total, 30-35 Gy), selected low-dose radiotherapy, also known as boom-boom radiotherapy, a regimen made up of 2 treatments of 2 Gy each (total, 4 Gy). Boom-boom radiotherapy is beneficial in selected cases of lymphoid disease to reduce localized toxicity. This treatment can be effective in the treatment of indolent non-Hodgkin lymphoma of the orbit and adnexa.