Value of Combined Diagnosis for Choroidal Lymphoma: A Case Report
Amit K. Arora
Round 1
Reviewer 1 Report
I found this paper to be of interest for publication. The comparison with VKH could be improved and clarified further.
Author Response
Dear Reviewer:
Thank you very much for your letter and the re-review comments to our manuscript entitled “The value of combined diagnosis in choroidal lymphoma: A case report”. We’re truly honored to have your appreciation for our work. We modify our paper as follows according to your comments.
Reviewer 1
The reviewer’s comment: I found this paper to be of interest for publication. The comparison with VKH could be improved and clarified further.
Response: Thank you for the suggestion. We have revised this section and integrated and simplified the sentences. Besides, we apologized for the poor language of our manuscript. We have polished our manuscript carefully and corrected the grammatical, styling and typos found in our manuscript. We really hope that the flow and language level have been substantially improved.
Kind regards
Dr Yang
Author Response File: 
Author Response.docx
Reviewer 2 Report
Thank you for the opportunity to review this article. Although the case could be interesting for readers, I would recommend a few changes to make it more acceptable for publication in this journal. The topic is definitely a rare and interesting presentation of high-grade B-cell lymphoma that would be beneficial for providers to learn more about. However, this report could be more valuable with the following changes being incorporated:
1. Provide laboratory values, especially complete blood counts and LDH that would be relevant to the diagnosis, staging and prognostication of lymphoma.
2. Since a histopathological diagnosis could not be achieved in this case, is it presumed that the CL is primary or secondary? Please elaborate on this.
3. What happened to the patient’s vision after they received Rituximab? Was there improvement/deterioration? Was an ophthalmological examination performed after Rituximab administration?
4. In regards to the patient’s status at the time of clinical deterioration with tumor lysis syndrome, could you clarify what ‘discharged’ means as this could be misinterpreted.
5. The report mentions using a combination of ophthalmic examination, aqueous humour detection, and pathological examination for diagnosis of CL. There was also a mention of IL-10/IL-6 ratio. Could you describe these diagnostic criteria in further detail including the significance of the IL-10/IL-6 ratio better. There appears to be a contradiction between the case and the discussion where Whitcup et al suggested the ratio of greater than 1 being diagnostic, but this case had a ratio of 0, therefore would not be diagnostic.
6. Provide more information on what this case is intending to achieve – are you are trying to emphasize rarity of the case or how to diagnose? Please describe this clearly.
7. Provide suggestions to readers. As this is a rare condition with limited information on diagnosis and treatment, it would be beneficial to describe these in detail. The suggestions to providers could be the diagnostic criteria as well as treatment options (local and systemic).
8. Please use sub headings in the discussion to make it easier to read.
9. Expand the discussion to include primary lymphoma of eye versus secondary, the diagnostic criteria, the survival data and treatment options. It would be useful to know what treatments have been shown to be effective historically.
10. A lot of the readers may not be Opthalmologists, and therefore may not be too familiar with some of the special tests that have been mentioned. Briefly explaining how each special imaging test works in a few words would be helpful.
Author Response
Dear Reviewer:
Thank you very much for your comments to our manuscript entitled “The value of combined diagnosis in choroidal lymphoma: A case report”. We’re truly honored to have your appreciation for our work. We have studied comments carefully and have made correction which we hope meet with approval. The main corrections in the paper and the responds as following.
- Provide laboratory values, especially complete blood counts and LDH that would be relevant to the diagnosis, staging and prognostication of lymphoma.
Response: Thank you for the suggestion. We have added the relevant hematological indicators. In addition, we have added immunohistochemical images and the results of aqueous humor puncture.
- Since a histopathological diagnosis could not be achieved in this case, is it presumed that the CL is primary or secondary? Please elaborate on this.
Response: Thank you for this comment. We tend secondary CL, which can be classified as a primary uveal lymphoma or secondary intraocular manifestation of systemic lymphoma. Primary CL is typically a low-grade lymphoma with late onset and slow disease progression, whereas secondary CL is often a comparatively high-grade lymphoma, characterized by a more rapidly progressive course. In our case, the liver, spleen, adrenal gland, and other important organs were involved, and the neck and axillary lymph nodes were enlarged. There were no ocular symptoms of vitreoretinal lymphoma in this case; however, there was systemic lymphoma. The disease rapidly progressed. The lymphoma cells spread to the choroid in the blood, causing secondary choroidal lymphoma. Unfortunately, we did not perform choroidal biopsy. However, we performed an axillary lymph node biopsy, which confirmed the diagnosis of non-Hodgkin diffuse large B-cell lymphoma.
- What happened to the patient’s vision after they received Rituximab? Was there improvement/deterioration? Was an ophthalmological examination performed after Rituximab administration?
Response: After receiving rituximab, the patient's condition deteriorated rapidly owing to secondary tumor lysis syndrome. The patient developed acute tumor lysis syndrome, myocardial injury, cardiac and renal insufficiency, hyperuricemia, hyperphosphatemia, and respiratory failure accompanied by repeated high fever, pulmonary infection, and intestinal fungal infection. When we went to the hematology department for rounds, we informed him at the bedside that his vision would not improve. Subsequently, the patient refused invasive examinations and discontinued treatment. Finally, the patient did not return to the ophthalmology department for further evaluation. We apologize for this.
- In regards to the patient’s status at the time of clinical deterioration with tumor lysis syndrome, could you clarify what ‘discharged’ means as this could be misinterpreted.
Response: We apologize for this error. We have revised it. The patient asked to be discharged and gave up treatment. During the telephone follow-up, we learned that he would die soon thereafter.
- The report mentions using a combination of ophthalmic examination, aqueous humour detection, and pathological examination for diagnosis of CL. There was also a mention of IL-10/IL-6 ratio. Could you describe these diagnostic criteria in further detail including the significance of the IL-10/IL-6 ratio better. There appears to be a contradiction between the case and the discussion where Whitcup et al suggested the ratio of greater than 1 being diagnostic, but this case had a ratio of 0, therefore would not be diagnostic.
Response: We apologize for this negligence. We have revised it. Your suggestions have been particularly valuable as this is an important finding. Although Whitcup et al. proposed that an IL-10/IL-6 ratio>1 is a diagnostic standard, when the ratio of IL-10/IL-6 detected in the aqueous humor is not greater than 1, it cannot be ruled out that lymphoma exists, because the tumor is confined to the choroid, the invasion depth does not break through the RPE layer, or even the retina enters the vitreous cavity. The IL-10/IL-6 ratio>1 is more valuable for the early diagnosis of vitreoretinal lymphoma.
- Provide more information on what this case is intending to achieve – are you are trying to emphasize rarity of the case or how to diagnose? Please describe this clearly.
Response: Thank you for this comment. We believe that the focus of this case is on early diagnosis, especially for those patients who first visited the ophthalmology department, that the possibility of choroidal lymphoma should be considered in time through the specific performance of OCT and other eye examinations, and early diagnosis and early treatment should be carried out as soon as possible through general examination to save lives. If we encounter this type of patient next time, we hope to go directly for a general examination as soon as possible, based on the specific performance of the eye to diagnose lymphoma, and begin systemic therapy.
- Provide suggestions to readers. As this is a rare condition with limited information on diagnosis and treatment, it would be beneficial to describe these in detail. The suggestions to providers could be the diagnostic criteria as well as treatment options (local and systemic).
Response: Thank you for your suggestion, and we added this part.
- Please use sub headings in the discussion to make it easier to read.
Response: Thank you for your suggestion. We have revised it.
- Expand the discussion to include primary lymphoma of eye versus secondary, the diagnostic criteria, the survival data and treatment options. It would be useful to know what treatments have been shown to be effective historically.
Response: Thank you for your suggestion. We have added this part and expanded the discussion in Section 3.1.
- A lot of the readers may not be Opthalmologists, and therefore may not be too familiar with some of the special tests that have been mentioned. Briefly explaining how each special imaging test works in a few words would be helpful.
Response: Thank you for your suggestion. We apologize for ignoring this, and we have revised it.
We tried our best to improve the manuscript and made some changes in the manuscript. Once again thank you very much for your comments and suggestion.
Thank you
Sincerely yours
Author Response File: Author Response.docx
Round 2
Reviewer 2 Report
Thank you for making the suggested changes. The revised article reads well and I believe that this case would add value for readers to know more about this rare entity, how to diagnose and manage it. Thank you for your efforts.
