Clinical characteristics of leukemic optic nerve infiltration in pediatric acute lymphoblastic leukemia: 3 cases and a literature review

Pediatric optic nerve infiltration in acute lymphoblastic leukemia (ALL) is a rare yet critical neuro-ophthalmic emergency, often signaling central nervous system (CNS) involvement or relapse. In this case series we present three cases of optic nerve infiltration in pediatric patients with ALL. The patients underwent systemic chemotherapy, intrathecal chemotherapy, and, in some instances, orbital radiation therapy, leading to varying degrees of visual recovery. In addition to presenting these cases, we review the existing literature and discuss the pathogenesis, clinical features, diagnostic approaches, imaging findings, and treatment strategies for this condition. Based on our cases and prior reports, we outline a practical diagnostic and treatment framework that prioritizes early recognition to reduce the risk of irreversible vision loss. For relapse or refractory disease, intensified therapy may be considered, including chimeric antigen receptor CD19 CAR T-cell therapy and hematopoietic stem cell transplantation. Optic nerve infiltration in ALL requires prompt, coordinated management among hematology, oncology, and ophthalmology specialists. Timely and appropriately intensified treatment may improve visual outcomes and survival.