case_images: PMC11082336_01
case_images: Fundus photographs, B-scan ultrasonography and swept-source Optical Coherence Tomography (SS-OCT) examinations at initial presentation. (A) Asteroid hyalosis and several subretinal yellow deposits were detected in the nasal retina of the right eye. (B) Moderate vitreous opacity, multiple subretinal yellow nodular lesions with varying sizes, streaky pigmentation (white arrowhead) and white exudation (asterisk) on the surface of several yellow subretinal nodules were detected in the left eye. (C) B-scan ultrasonography showed clusters of moderately or highly condensed punctate echoes in vitreous cavity, and irregular hypoechoic lesions (yellow arrows) under the retina of the left eye. (D,E) Infrared image and SS-OCT images with scanning length of 24 mm of the left eye. Homogenous hyperreflective lesions in the sub-RPE space were detected in the peripheral retina. An enlarged inset is provided on the right.
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case_images: PMC11082336_01_fmed-11-1386979-g001.jpg
case_images: fig1
case_images: Mild vitreous opacity with asteroid hyalosis, and several subretinal yellow lesions in the nasal peripheral fundus was observed in the right eye (Figure 1A). Moderate vitreous opacity, multiple subretinal yellow nodular lesions with varying sizes, streaky pigmentation and white exudation on the surface of several yellow subretinal nodules were detected in the left eye (Figure 1B). B-scan ultrasonography showed clusters of moderately or highly condensed punctate echoes in vitreous cavity and irregular hypoechoic lesions under the retina of the left eye (Figure 1C). Vessel density map of SCP layer demonstrated several warm hues dots corresponding to these hyperflow spots, and they were distributed along the retinal vessels (Supplementary Figure S1). Homogenous hyperreflective lesions sub-RPE space in the peripheral retina could also be detected by 24 mm OCT scan (Figures 1D,E).
case_images: One typical intraretinal hyperflow microinfiltration lesions located beneath superficial retinal vessel on Swept-Source Optical Coherence Tomography Angiography (SS-OCTA) with scanning areas of 6 mm x 6 mm of the left eye (A1-G1) before and (A2-G2) after induction phase of intravitreal methotrexate injections. (A1) SS-OCTA image of (superficial capillary plexus) SCP layer showed no abnormal blood flow signals correlated with lymphoma. (B1) SS-OCTA image of retinal deep capillary plexus (DCP) layer showed several hyperflow spots. (C1)
  Enface SS-OCTA structural images of SCP layer showed no abnormal reflectance correlated with lymphoma. (D1)
  Enface SS-OCTA structural images of DCP layer showed multiple hyperreflective lesions. (E1,F1) SS-OCT B-scan with flow overlay of (E1) SCP layer and (F1) DCP layer showed inhomogenous flow signals of the vertical intraretinal hyperreflective lesion. The boundary of flow signals overlaid on the vertical intraretinal hyperreflective lesions was difficult to clearly distinguish from the flow signals of retinal vessels above them. (G1) SS-OCT showed outer retina with fuzzy borders and the vertical hyperreflective lesion extended from retinal nerve fiber layer to RPE. The hyporeflective vascular wall boundary of vessels above intraretinal infiltrations was absent. (A2) SS-OCTA image of SCP layer showed no great difference from A1. (B2) SS-OCTA image of DCP layer showed the preexisting hyperflow spots almost disappeared. (C2)
  Enface SS-OCTA structural images of SCP layer showed no great difference from C1. (D2)
  Enface SS-OCTA structural images of DCP layer showed the preexisting hyperreflective lesions almost disappeared. (E2,F2) SS-OCT B-scan with flow overlay of (E2) SCP layer and (F2) DCP layer showed the preexisting hyperflow signals of the vertical intraretinal hyperreflective lesion almost disappear. (G2) SS-OCT showed the corresponding vertical hyperreflective lesions almost vanished, outer retina fuzzy borders were in remission.
case_images: fmed-11-1386979-g002.jpg
case_images: PMC11082336_01_fmed-11-1386979-g002.jpg
case_images: fig2
case_images: Technology, Beijing, China) revealed outer retina with fuzzy borders and one vertical hyperreflective lesion in the posterior pole of fundus of the left eye (Figure 2G1). SS-OCTA image of superficial capillary plexus (SCP) layer with scanning areas of 6 mm x 6 mm showed no abnormal blood flow signals of the left eye (Figure 2A1). Multiple hyperflow signals corresponding to the vertical hyperreflective lesions on SS-OCT were unexpectedly demonstrated on the enface SS-OCTA images of DCP layer (Figure 2B1), which were more pronounced on the enface structural image of DCP layer (Figure 2D1). The enface structural image of SCP layer showed no abnormal reflectance correlated with lymphoma (Figure 2C1). SS-OCT B-scan with flow overlay of SCP layer and DCP layer showed inhomogenous flow signals of the vertical intraretinal hyperreflective lesion (Figures 2E1,F1). Furthermore, outer retina fuzzy borders were in remission in the left eye, and ellipsoid zone and external limiting membrane could be recognized on SS-OCT (Figures 2E2-G2). The preexisting hyperflow spots on SS-OCTA images of DCP layer almost disappeared (Figure 2B2). SS-OCTA structural images of DCP layer also showed the preexisting hyperreflective lesions almost disappeared (Figure 2D2). SS-OCTA image of SCP layer and enface SS-OCTA structural images of SCP layer showed no great difference from pre-treatment images (Figures 2A2,C2).
case_images: Swept-Source Optical Coherence Tomography Angiography (SS-OCTA) examinations of the right eye at initial presentation. (A) SS-OCTA image of superficial capillary plexus (SCP) layer. (B) SS-OCTA image of retinal deep capillary plexus (DCP) layer. (C)
  Enface SS-OCTA structural images of SCP layer. (D)
  Enface SS-OCTA structural images of DCP layer. (A-D) showed no obvious abnormality correlated with lymphoma. (E,F) SS-OCT B-scan centered on the fovea with flow overlay of (E) SCP layer and (F) DCP layer showed no obvious abnormal blood flow signals correlated with lymphoma. (G) SS-OCT showed several vitreous cells (white arrows).
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case_images: PMC11082336_01_fmed-11-1386979-g003.jpg
case_images: fig3
case_images: Notably, neither similar vertical hyperreflective lesions in SS-OCT nor hyperflow spots in SS-OCTA were detected in the posterior pole of the right eye (Figure 3).
case_images: Intraoperative fundus image, cytology and immunohistochemical test of the vitreous after surgery, fundus photographs examinations after induction phase of intravitreal methotrexate injections. (A) Intraoperative fundus image showed multiple subretinal yellow nodular lesions with varying sizes, streaky pigmentation and white exudation (surgeo's view). (B) The vitreous was infiltrated with numerous lymphocytes (white arrows) (hematoxylin and eosin x400). (C) Immunohistochemical stains are positive for CD20 in the lymphocytes (peroxidase anti-peroxidase x400). (D) The number and size of white-yellow subretinal lesions in the nasal retina of the right eye were reduced. (E) The opacity of vitreous disappeared. The number and size of white-yellow subretinal lesions were reduced obviously. White exudation (asterisk) on the surface of yellow subretinal nodules in the inferior peripheral fundus also diminished.
case_images: fmed-11-1386979-g004.jpg
case_images: PMC11082336_01_fmed-11-1386979-g004.jpg
case_images: fig4
case_images: We strongly suspected the possibility of PVRL and performed diagnostic 23 gauge-vitrectomy for his left eye (Figure 4A). Cytology unveiled atypical lymphocytes with an elevated nucleus/cytoplasm ratio and multiple prominent nucleoli (Figure 4B). Lymphoma cells in the vitreous presented positive B-cell marker of CD20, CD79a, Bcl-2 and Bcl-6, with a high Ki-67 positive rate of 30-40% (Figure 4C). Moreover, the white exudation on the surface of yellow subretinal nodules in the inferior peripheral fundus of the left eye also diminished (Figures 4D,E).