How Retinal Imaging Can Save a Life: A Case Study

As a primary care optometrist, the majority of my patients every day are scheduled for routine comprehensive exams.  It's time to update their glasses and contact lens prescriptions; no significant vision or pain complaints. I'm a strong believer that at every routine exam we should also do an ocular health assessment, even when the patient has no complaints about their eyes or vision. Unfortunately the eye is a body part that isn't very good at telling us when something is wrong.  Most blinding conditions of the eye, and most systemic conditions that steal sight have absolutely no symptoms -- no pain, no vision changes -- until you are permanently blind.  I know you and I wouldn't want to wait that long to find them.  I want to share this real case from my practice as a great example about why routine health care should always include dilation and/or retinal imaging.  This patient and his team of medical doctors are very happy that he didn't skip the dilation or imaging this year.

The Case:
47 year old white male presents for routine eye exam with no vision complaints.  Only known medical condition is hyperthyroidism, for which he takes levoxyl.  He had LASIK a few years ago and is 20/20 in both eyes without any glasses prescription required.  All ocular health is normal, even his eye pressure (11 and 10 mmHg in right and left eye respectively).  But then we look at his retinal imaging and we see this:

Right Eye:

Left Eye:

To the untrained eye, the multiple hemorrhages in these photographs might be hard to spot.  The photos below have been color and brightness enhanced to better visualize the bleeding going on in the retina:

Right Eye:

Left Eye:

Both eyes have multiple intraretinal hemorrhages scattered throughout.  The most obvious can be seen inferiorly on the right eye photograph -- they look like red blotches in the retina.  Whenever we find bleeding in the eye, the usual culprit is a systemic vascular condition.  High blood pressure and diabetes are two common systemic conditions that cause retinal hemorrhages.  But this patient had never been diagnosed with any vascular condition, and he saw his primary care doctor regularly. Blood work was ordered and the results came back with elevated white blood cell count.  Further testing confirmed the diagnosis: chronic myeloid leukemia.

Chronic myeloid leukemia (or CML) is a cancer of the bone marrow, disrupting the body's ability to make platelets, red blood cells, and white blood cells.  In the chronic stage of this cancer, most patients are completely asymptomatic.  They might feel fatigue or joint pain, but our patient had neither complaint.  Luckily with treatment the chance for survival with CML is very good.  A 2011 study of Gleevic found a survival rate of  95.2% of treated patients after 8 years.  With early intervention, the treatment has even better chances for success.  Interestingly, only 5-10% of patients with CML present with ophthalmic signs or symptoms at initial diagnosis, but those that do have retinal hemorrhaging or other associates retinal findings like optic nerve edema have a lower 5 year survival rate:  21.4% compared to 45.7% of those without.   That's why finding signs like retinal bleeds and getting the proper blood work is so essential  -- if the signs are there but aren't caught, the patient has a much lower chance of survival.  But if these signs are found during routine eye exams, the patient can get treatment much faster and earlier in the disease process, and improve their chance for survival!

This case is a great story about how routine health care is the best way to protect your health. Whenever you are tempted to blow off your annual exam, or skip that dilation because it's not convenient, think about that possibility that today's eye exam could save your life.