Acute Lymphoblastic Leukaemia can affect the eye in various ways . It may present with an ischaemic optic nerve involvement (1) or optic nerve swelling due to direct involvement . But sometimes it may also present as an optic nerve involvement as an effect of a drug like Linezolid which has been used for treatment of infections which coexist (2) or it may present as an infiltration of the nerve in combination with herpes virus (3)

Though papillodema is the most frequent sign of optic nerve involvement it can be absent in direct infiltration of the nerve by leukemic cells, or present just due to increased intracranial pressure , or swelling because of retrolaminar leukemic invasion.

The involvement in invasion of the optic nerve usually occurs during the evolution of acute lymphoblastic leukemia, but that , when as is elucidated in the present case and also by Mess et al earlier in 2003, is the first sign of acute lymphoblastic leukemia or of extramedullary relapse after remission , it usually means a poor prognosis for the patient, especially if it happens when the patient is still receiving treatment, rather than after it. And so earlier it is picked up, the better .Hence the value of a routine check even in absence of symptoms .

Optic nerve swelling may mean many things and one needs to differentiate the causes of the optic nerve swelling clinically and with non invasive tests like Ocular coherence tomography ( OCT ) so as to institute proper therapy . Optic nerve involvement, as one needs to emphasise again , is not always a result of leukaemia infiltration as a surprise in remission . Sometimes Peripapillary retinal leukemic infiltration may be associated with papilledema in a patient without cranial or optic nerve involvement.(4) . Optic nerve swelling may be seen due to optic neuritis (5) which can be seen sometimes in cases of leukaemia without leukaemic infiltration .Sometimes the peri neuritis may be transient (6) Papillodema due to central nervous system involvement may be seen .Medications used for treatment may sometimes cause secondary optic nerve affectation and may include but be not limited to toxicity of chemotherapy, antibiotics or radiotherapy, ischemia after anaemia or hyperviscosity, and opportunistic infections in immunocompromised patients. In such cases to figure out whether the optic nerve involvement is indeed direct infiltration one may look for other layers of eye being involved . (7) So if there are other layers involved there is a clue and an eye surgeon will pick it up because conjunctival , scleral and trabecular involvement is characteristic

But in a case where optic nerve alone is involved one can use OCT to figure out what's hapenning at the optic nerve level. The swelling begins not at superior or inferior edge of the optic nerve as in papillodema due to raised intra cranial pressure and "doesn't follow ISNT rule " ( that's a rule in glaucoma where loss occurs in that order but sometimes swellings occur in similar way ) and also one doesn't see a typical swelling of optic neuritis then it's obvious that a lot of clues are waiting to be picked up

The present case report helped us manage a case locally and so we are thankful to the authors and the journal for the same

The optic nerve is relatively unaffected by systemic chemotherapy and serves as a sanctuary of ALL.(8) So it is probably essential that an eye surgeon opinion is sought regularly since there's a lot they can tell , lots more than meets the non ophthalmologist's eye .

Reference :-

1) Chaudhuri T, Roy S, Roy P. Ischaemic optic neuropathy induced sudden blindness as an initial presentation of acute lymphoblastic leukemia. Indian J Med Paediatr Oncol 2013;34:335-6

2) Joshi L, Taylor SRJ, Large O, Yacoub S, Lightman S (2009). A case of optic neuropathy after short-term linezolid use in a patient with acute lymphocytic leukemia. Clin Infect Dis 48:73-74. ISSN 1537-6591.

3) Bhatt UK, Gregory ME, Madi MS, Fraser M, Woodruff HA (2008). Sequential leukemic infiltration and human herpervirus optic neuropathy in acute lymphoblastic leukemia. Journal of AAPOS 12:200-202. ISSN 1528-3933.

4) ?eki? O, Biberoglu E, Esen F. Peripapillary retinal leukemic infiltration associated with papilledema in a T-ALL patient without cranial or optic nerve involvement. Tumori. 2016 Nov 11;102(Suppl. 2). doi: 10.5301/tj.5000490

5) Yo Han Ra, Sun Young Park, Soo Ah Im, Jee Young Kim, Nak Gyun Chung, Bin Cho. Enhancement of Optic Nerve in Leukemic Patients: Leukemic Infiltration of Optic Nerve versus Optic Neuritis.iMRI 2016;20:167-174. http://dx.doi.org/10.13104/imri.2016.20.3.167

6) Townsend JH, Dubovy SR, Pasol J, Lam BL. Transient optic perineuritis as the initial presentation of central nervous system involvement by pre-B cell lymphocytic leukemia. J Neuroophthalmol 2013;33:162-164

7) Rosenthal AR. Ocular manifestations of leukemia. A review. Ophthalmology 1983;90:899-905

8) Ninane J, Taylor D, Day S. The eye as a sanctuary in acute lymphoblastic leukemia. Lancet. 1980;1:452-3.

Conflict of Interest:

None declared

Zaidi et al conclude that "Dietary supplements, such as curcumin, may be beneficial for some myeloma patients". This is on the basis of their single case report; in other words it is an anecdote. In contrast, the medicinal chemistry of curcumin has been studied in depth for many years. Nelson et al conclude that, despite over 120 clinical trials, no beneficial effect has been observed (1).

I am wondering about how rigorous was the peer review of this case report. Did the reviewers evaluate what was the more likely explanation, in the light of the published literature?

I note that Zaidi et al cite a review by Aggarwal et al in 2009 (2). Several papers from this author were withdrawn in or about 2012 as possibly fraudulent (3), casting doubt on his authority. I do not think this oversight reflects well on the authors of the present case report, or on its reviewers.

This case report has recently attracted substantial attention from the lay media. Exaggerated claims have been made on national radio. Yet there is good evidence that cancer patients who rely on alternative treatments such as plant extracts have worse outcomes (4). Was it really responsible of the BMJ to publish this report in its present form?

References

1. Nelson KM, Dahlin J, Bisson J et al. The Essential Medicinal Chemistry of Curcumin. J Med Chem. 2017 Mar 9; 60(5): 1620-1637.

2. Aggarwal BB, Harikumar KB. Potential therapeutic effects of curcumin, the anti-inflammatory agent, against neurodegenerative, cardiovascular, pulmonary, metabolic, autoimmune and neoplastic diseases. Int J Biochem Cell Biol 2009;41:40-59.

3. Ackerman T. M.D. Anderson scientist, accused of manipulating data, retires. Houston Chronicle, March 2, 2016 Updated: March 4, 2016. http://bit.ly/2AHTN20 (accessed 8th Jan 2018)

4. Johnson SB, Park HS, Gross CP et al. Use of Alternative Medicine for Cancer and Its Impact on Survival. Journal of the National Cancer Institute, Volume 110, Issue 1, 1 January 2018

Conflict of Interest:

I have had smouldering myeloma for nine years but have not required treatment.

Varying sizes and quality of clots are seen in severe rheaumatic mitral valve stenosis, especially in Asian subcontinent. LA clots are also found in patients with non-valvular atrial fibrillation, but to a lesser extent as compared to rheumatic valvular disesase and are seen more in the advanced world. The clots can be fresh ones or multilayered organised clots or a mixture of the two. In severe mitral stenosis, because of the obvious stasis of blood in LA, there are high possibilities of clot formation, and this is seen more so in the Indian subcontinent due to poor patinet compliance with anticoagulation therapy and this is a major issue in the management of patients with rheumatic mitral stenosis.This leads to various complications such as Stroke, TIA, and embolisation to various other systemic organs and lower limbs ausing ischemia. It is important to treat these patients as an urgent case for LA clot removal and Mitral valve repalcement along with surgical management of lower limb ischemia.

Conflict of Interest:

None declared

We read with interest this case series having seen several nerf gun eye injuries in our own department. A search of the electronic patient records revealed 17 such cases since 2014. Of these 12 were male and 5 female with 9 under the age of 18. Analysis of the primary injury revealed 5 hyphemas, 5 cases of traumatic iritis, 2 corneal abrasions, 1 case of commotio retinae and 1 case of angle recession with the risk of glaucoma.

In addition this placed an additional strain on an already stretched eye casualty as many of the patients required treatment with an average of 3 visits with 1 patient requiring 8 visits.

We therefore support the authors call for patients and parents to be aware of the types of 'bullets' used and to use eye protection to prevent significant eye injuries.

Conflict of Interest:

None declared