Cytopathological analysis of vitreous in intraocular lymphoma L Intzedy 1 , SCB Teoh 2,3,4 , A Hogan 2 , S Mangwana 1 , EJ Mayer 2,4 , AD Dick 2,4 and J Pawade 1 Abstract Objective To describe the cytopathological method used in the analysis of vitreous samples in the diagnosis of primary intraocular lymphoma (PIOL). Participants Seven patients with refractory posterior uveitis referred to a regional ocular inflammatory service were diagnosed as having PIOL between 1999 and 2006. Methods Clinical features of the uveitis and cytopathological preparation of the samples were described. All patients underwent vitrectomy and samples were placed in formal saline or prepared fresh. Following paraffin embedding generating a cell block, immunostaining, and polymerase chain reactions were performed. Results Five women (71.4%) and two men (28.6%) (mean age 67.7 years) were included. Five patients had diagnostic vitrectomy performed within 6 months of presentation, but in two patients diagnosis was delayed up to 2 years. Uveitis was bilateral in two patients. Cytologic and immunohistochemical staining prepared from the vitreous specimens showed PIOL in all patients, and PCR displayed single band of immunoglobulin heavy chain rearrangement in five out of six samples tested. Conclusions Diagnosis of PIOL is difficult due to small volume of sample with low number of malignant cells and inadequate preparation of samples. Our method of analysis with fresh samples together with immunohistochemistry and PCR analysis demonstrates a high yield of diagnosis reducing diagnostic delay. Eye (2008) 22, 289–293; doi:10.1038/sj.eye.6702965; published online 31 August 2007 Keywords: intraocular lymphoma; eye; vitrectomy; cytopathology; immunochemistry; polymerase chain reaction Introduction Malignant lymphoma is the generic term describing tumours of the lymphoid system and are divided into two major categories: Hodgkin’s lymphoma and non-Hodgkin’s lymphomas (NHL). Hodgkin’s lymphomas are rare at extranodal sites such as eyes. Intraocular presentation in NHL, although more common, is estimated to represent only about 1% of cases, 1 either as (1) ocular involvement in primary central nervous system (CNS) lymphoma, or (2) systemic NHL with spread to the uveal tract, or (3) rarely as a primary intraocular event. Primary CNS lymphoma is a high-grade non- Hodgkin’s lymphoma restricted at presentation to the brain, spinal cord, or meninges. A proportion of these cases (17%) show eye involvement only, at initial presentation. About 60% of patients presenting with intraocular NHL will develop lymphomatous infiltrates of the brain, spinal cord, or meninges later. 1 Most intraocular lymphomas are of B-cell phenotype. Rare cases of T-cell lymphoma with intraocular involvement have been reported mostly representing a secondary manifestation of either a cutaneous or a systemic lymphoma. Intraocular lymphoma has a poor prognosis with a median survival of just over 3 years with treatment, 2 and once CNS involvement occurs, an untreated median survival is 1.8–3.3 months. 3 Aggressive modern-day treatments can prolong this median survival to 40 months, 4 with ocular management improving vision during this time. Primary ocular NHL often presents as a masquerade syndrome with features of posterior uveitis, which can result in diagnostic delays. The average interval from onset of ocular symptoms to diagnosis was still 11–21.4 months even in tertiary uveitis referral centres. 5,6 This interval can be decreased with an increased index of suspicion. Most significant cause of delay is inadequate Received: 12 April 2007 Accepted in revised form: 22 July 2007 Published online: 31 August 2007 Proprietary interests: The authors declare that they have no financial or proprietary interests in the products described in the study 1 Department of Pathology, Bristol Royal Infirmary, Bristol, UK 2 Bristol Eye Hospital, Bristol, UK 3 The Eye Institute, Tan Tock Seng Hospital, Singapore 4 Department of Clinical Sciences South Bristol, University of Bristol, Bristol Eye Hospital, Bristol, UK Correspondence: J Pawade, Department of Pathology, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK Tel: þ 44 117 928 2869; Fax: þ 44 117 929 2440. E-mail: Joya.Pawade@ ubht.nhs.uk Eye (2008) 22, 289–293 & 2008 Nature Publishing Group All rights reserved 0950-222X/08 $30.00 www.nature.com/eye LABORATORY STUDY