Enhancing Detection and Diagnosis of Intraocular Lymphoma Through Advanced Retinal Imaging

Intraocular lymphoma is traditionally defined by cytopathology, yet in contemporary practice the disease is increasingly recognised through imaging well before tissue confirmation. Advances in retinal imaging, particularly optical coherence tomography (OCT), have reshaped how clinicians detect and diagnose vitreoretinal lymphoma (VRL). The review by Ibrahim and Dalvin provides a timely synthesis of multimodal retinal imaging features across lymphoma subtypes and highlights how structural and angiographic modalities now guide clinical evaluation 1. Rather than serving merely as an adjunct to pathology, imaging is evolving into a defining framework through which intraocular lymphoma is managed. OCT is emerging as a transformative tool in the evaluation of ocular lymphoma 2. Characteristic findings such as sub-retinal pigment epithelium infiltrates, band-like subretinal lesions and vertical hyperreflective lesions represent recurring patterns observed across biopsy-proven cohorts 3, 4. Large OCT series suggest that sub-RPE infiltrates, often masquerading as drusen or drusenoid pigment epithelial detachments, may be among the most consistent structural hallmarks of VRL 4. Beyond these established findings, preretinal lesions are gaining increasing attention. While small superficial deposits are commonly illustrated, larger preretinal proliferations may assume a distinctive stalagmite-like configuration projecting towards the vitreous cavity (Figure 1). This ‘stalagmite’ morphology is not exclusive to lymphoma (e.g., another aetiology is fungal endophthalmitis) but represents a striking imaging sign that should immediately raise suspicion for VRL in the appropriate clinical context. Recognition of these lesions emphasises how OCT continues to expand from descriptive imaging towards pattern-based diagnostic reasoning. OCT angiography (OCTA) 5, 6 has introduced a vascular perspective to lymphoma imaging. Emerging studies describe perivascular microinfiltration patterns and hyperflow signals that may reflect early lymphomatous spread along retinal vessels. These findings suggest that imaging could detect biologic activity before overt structural disruption becomes apparent. While preliminary, OCTA may eventually allow clinicians to monitor disease dynamics rather than structural consequences alone, particularly in the context of intravitreal chemotherapy. Whereas OCT dominates the evaluation of vitreoretinal disease, ultrasonography retains an important role in choroidal lymphoma. B-scan ultrasound may reveal characteristic diffuse choroidal thickening with echolucent infiltration, occasionally extending beyond the globe into the orbital tissues 7. These ultrasonographic patterns, particularly in mucosa-associated lymphoid tissue lymphoma (MALToma), are highly suggestive and even diagnostic and provide complementary information when OCT findings are subtle or ambiguous 8. The integration of ultrasonography with OCT underscores the importance of multimodal imaging in recognising the full spectrum of ocular lymphoma (Figure 2). Despite remarkable progress, most imaging descriptions remain qualitative. Terms such as ‘cloudy vitelliform lesions’, ‘fuzzy outer retina’, or ‘seasick’ choroidal undulations convey recognisable patterns but lack measurable thresholds. The next evolution in intraocular lymphoma imaging will likely depend on quantification. Automated segmentation, volumetric OCT analysis and multimodal integration could transform descriptive observations into objective biomarkers capable of monitoring tumour burden and predicting relapse. Delayed diagnosis still remains a concern because intraocular lymphoma frequently mimics inflammatory uveitis 9, 10. The Ibrahim and Dalvin review highlights how multimodal imaging raises suspicion but rarely provides definitive differentiation 1. Rather than viewing this overlap as a limitation, it may represent an opportunity to refine research priorities. Comparative masquerade cohorts and longitudinal imaging studies will be essential to distinguish infiltrative patterns from inflammatory structural changes. Structural OCT, fundus autofluorescence and angiography provide complementary structural and metabolic insights, while OCTA introduces a functional dimension that may capture disease earlier than conventional modalities. At the same time, ultrasonography remains indispensable for certain lymphoma subtypes, reminding clinicians that no single modality defines the disease. The analysis provided by Ibrahim and Dalvin reflects a broader transition within ophthalmology: intraocular lymphoma is increasingly recognised not only through pathology but through a coherent imaging phenotype. As imaging advances towards quantitative analysis, vascular biomarkers and longitudinal monitoring, it may fundamentally reshape how masquerade syndromes are understood and managed. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.