Sir,

Primary intraocular lymphoma (PIOL) is well known for its mimicry of other ocular diseases and its propensity to evolve.1 We managed a patient who presented with a picture of multifocal choroiditis and panuveitis, but subsequently developed more characteristic lesions.

A 73-year-old male had poor vision of the left eye after cataract surgery 4 months earlier. His ophthalmologist had been treating him for cystoid macular oedema.

Examination showed corrected visual acuity of 20/30 right eye and 20/200 left eye. Both eyes had 1+ anterior vitreous cells. Both fundi showed atrophic pigment epithelial lesions in the mid-periphery (Figure 1). In the right temporal periphery, a tan subretinal lesion was seen and was interpreted as an eccentric disciform scar (Figure 2). The left macula had cystoid oedema (Figure 3).

Figure 1
figure 1

Black and white fundus photograph of the left eye shows atrophic pigment epithelial lesions in the mid-periphery at presentation.

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Figure 2
figure 2

Black and white fundus photograph of the right eye shows a tan subretinal lesion in the right temporal periphery present initially, which was interpreted as an eccentric disciform scar. It later spontaneously resolved.

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Figure 3
figure 3

Fluorescein angiography of the left macula at presentation shows cystoid oedema.

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The initial diagnosis was multifocal choroiditis and panuveitis. RPR, FTA-ABS, Lyme antibody titres, and Epstein–Barr virus antibody titres were normal. Empirical therapy with acyclovir 600 mg orally four times daily and a subconjunctival injection of triamcinolone acetonide 20 mg in the left eye was given.2 At 2 months there were no changes.

Four months later, the temporal subretinal lesion of the right eye had resolved and new retinal infiltrates and haemorrhages of the left eye were present (Figure 4). Vitreous biopsy revealed lymphoma. MRI scan revealed no central nervous system lesions, and spinal fluid was normal. Craniospinal irradiation and intrathecal methotrexate were administered. The patient was well for 7 years until fatal relapse developed.

Figure 4
figure 4

Colour fundus photograph of the left eye 4 months after initial presentation shows new retinal infiltrates and haemorrhages.

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The clinical presentations of primary intraocular lymphoma include subretinal deposits, vitritis, retinitis, infiltrative optic neuropathy, iritis, scleritis, and multiple evanescent white dot syndrome-like appearances.3 In this case, the clinical picture was compatible with multifocal choroiditis and panuveitis. The subretinal deposit of lymphoma resolved simultaneously with the fellow eye appearance of white retinal infiltrates and haemorrhage, a picture associated with PIOL.4 Clinicians faced with a picture of multifocal choroiditis and panuveitis in an elderly patient should include primary intraocular lymphoma in the differential diagnosis and consideration of vitreous biopsy given. Early treatment has been associated with improved survival.5