The Silent Masquerade: Clinical and Imaging Features of Asymptomatic Vitreoretinal Lymphoma

Purpose To report and characterize ocular features of asymptomatic vitreoretinal lymphoma (VRL) associated with primary central nervous system lymphoma (PCNSL), by examining clinical and multimodal imaging characteristics and comparing with symptomatic VRL. Design Retrospective cross-sectional study. Methods Patients with cytologically or molecularly confirmed VRL were included. Patients were classified into three groups: primary VRL (PVRL), symptomatic VRL associated with PCNSL (PCNSL-S), or asymptomatic VRL associated with PCNSL (PCNSL-AS). Data encompassing demographics, visual symptoms, visual acuity (VA), and imaging characteristics were collected. Cross-sectional analyses of quantitative and categorical variables among groups were performed with one-way ANOVA and multinomial linear regression analyses. Results The study included 104 eyes from 56 patients with VRL. Twenty-nine patients (52%) were diagnosed with PVRL, and 27 patients (48%) were diagnosed with VRL associated with PCNSL. Among these, 17 (63%) reported visual symptoms (PCNSL-S), whereas 10 (37%) were asymptomatic (PCNSL-AS). PCNSL-AS patients exhibited better VA than PVRL patients (0.11 vs. 0.76 LogMAR, p=0.04) and distinct clinical features, with lower rates of anterior segment involvement (odds ratio [OR]=0.02; 95% confidence interval [CI] 0.12-0.84; p<0.01) and vitritis (OR= 0.32; 95%CI 0.11-0.91; p=0.03). Subretinal infiltration was less common in PCNSL-AS cases compared to PVRL (OR= 0.14; 95%CI 0.02-1.11; p=0.06) and PCNSL-S (OR: 0.08; 95%CI 0.01-0.69 p=0.05) and was associated with worse VA (estimate=0.55 LogMAR; 95%CI 0.29-0.8; p<0.01). Conclusion This study describes distinctive clinical and imaging features of asymptomatic VRL associated with PCNSL, characterized by better VA and less severe ocular involvement. The findings highlight the pivotal role of multimodal imaging in facilitating early detection of VRL in the staging of PCNSL. Future guidelines for PCNSL management should consider the necessity of diagnosing patients with asymptomatic VRL.