Ocular manifestations of multiple myeloma, Waldenström's macroglobulinemia and benign monoclonal gammopathy

Subretinal autofluorescent deposits: A review and proposal for clinical classification

Subretinal autofluorescent deposits (SADs) may be found in the posterior pole, associated with very various conditions. These disorders usually present a typical pattern of autofluorescent lesions seen on short-wavelength fundus autofluorescence. We describe SADs according to their putative pathophysiological origin and also according to their clinical pattern, i.e., number, shape, and usual location. Five main putative pathophysiological origins of SADs were identified in disorders associated with an intrinsic impairment of phagocytosis and protein transportation, with excess of retinal pigment epithelium phagocytic capacity, with direct or indirect retinal pigment epithelium injury, and/or disorders associated with long-standing serous retinal detachment with mechanical separation between the retinal pigment epithelium and the photoreceptor outer segments. Clinically, however, they could be classified into eight subclasses of SADs, as observed on fundus autofluorescence as follows: single vitelliform macular lesion, multiple roundish or vitelliform lesions, multiple peripapillary lesions, flecked lesions, leopard-spot lesions, macular patterned lesions, patterned lesions located in the same area as the causal disorder, or nonpatterned lesions. Thus, if multimodal imaging may be required to diagnose the cause of SADs, the proposed classification based on noninvasive, widely available short-wavelength fundus autofluorescence could guide clinicians in making their diagnosis decision tree before considering the use of more invasive tools.

Ocular complications of plasma cell dyscrasias

Plasma cell dyscrasias are a wide range of severe monoclonal gammopathies caused by pre-malignant or malignant plasma cells that over-secrete an abnormal monoclonal antibody. These disorders are associated with various systemic findings, including ophthalmological disorders. A search of PubMed, EMBASE, Scopus and Cochrane databases was performed in March 2021 to examine evidence pertaining to ocular complications in patients diagnosed with plasma cell dyscrasias. This review outlines the ocular complications associated with smoldering multiple myeloma and monoclonal gammopathy of undetermined significance, plasmacytomas, multiple myeloma, Waldenström's macroglobulinemia, systemic amyloidosis, Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy and Skin changes (POEMS) syndrome, and cryoglobulinemia. Although, the pathological mechanisms are not completely elucidated yet, wide-ranging ocular presentations have been identified over the years, evolving both the anterior and posterior segments of the eye. Moreover, the presenting symptoms also help in early diagnosis in asymptomatic patients. Therefore, it is imperative for the treating ophthalmologist and oncologist to maintain a high clinical suspicion for identifying the ophthalmological signs and diagnosing the underlying disease, preventing its progression through efficacious treatment strategies.

The Spectrum of Ocular Manifestations in Patients with Waldenström's Macroglobulinemia

PURPOSE

To investigate the ocular manifestations in 91 Waldenström's macroglobulinemia (WM) patients.

METHODS

Retrospective, cross-sectional, observational analysis.

RESULTS

Ocular impairments, detected in 19 patients, included flame-shaped hemorrhages, venous sausaging, papilledema, macular detachments, or central retinal vein occlusion in 16 patients; paraproteinemic keratopathy in 2; and a CANOMAD syndrome in 1. Best-corrected visual acuity was ≥0.5 logMAR units in 11 of 38 eyes. Intraocular pressure was increased in seven eyes. Genetic analysis in seven patients showed a mutation in the MYD88 gene in six patients and a nonsense mutation in the CXCR4 gene in five patients. Plasmapheresis followed by chemotherapy with or without the addition of rituximab resulted in improvement or normalization of the ophthalmological findings in 15 patients.

CONCLUSION

The ocular manifestations of WM are protean and potentially sight threatening. Recent advances in genomic profiling and chemotherapy have remarkably improved the hematological and ophthalmological outcomes of these patients.

Choroidal Manifestation of Smoldering Myeloma: Case Report

This case illustrates clinical, histopathological, immunohistochemical, and molecular pathological diagnostic testing of smoldering myeloma with atypical ophthalmic manifestations. In our case, the choroidal lesion presented as a solitary manifestation of a systemic disease. Choroidal lesions of monoclonal plasma cells are extremely rare and should be included in the differential diagnosis of amelanotic choroidal lesions, even if the histopathological examination of the primary lesion is not informative. Clinical course, immunohistochemistry, and molecular pathology are essential components of the diagnostic pathway.

Ocular involvement in TEMPI syndrome

Purpose

We report the first case of ocular involvement in TEMPI syndrome, a rare disease characterized by telangiectasias, elevated erythropoietin with erythrocytosis, monoclonal gammopathy, perinephric fluid collections, and intra-pulmonary shunting.

Observations

A 64-year-old Caucasian man with history of TEMPI syndrome presented with subacute bilateral painless vision loss. Ocular examination showed chronic retinal ischemia with microvascular damage, which was likely associated with the chronic systemic hypoxemia, and spontaneous wax and wane of cystoid macular edema, presumedly related to the systemic bortezomib treatment.

Conclusions and importance

Our case demonstrates that pathologic retinal vascular changes could be seen in association with TEMPI syndrome and suggests that a comprehensive ophthalmological examination may be beneficial for these patients.

Retinal Microvascular Changes in Patients with Multiple Myeloma: A Study Based on Optical Coherence Tomography Angiography

PURPOSE

Ocular microvascular networks and variables were analyzed using optical coherence tomography angiography (OCTA) in patients with multiple myeloma (MM) who had no pathological findings in their routine ophthalmologic examinations.

MATERIALS AND METHODS

The study included 31 patients with a diagnosis of MM and 30 healthy controls. The ophthalmologic examination findings and OCTA measurements of the participants were prospectively analyzed. We evaluated the superficial capillary plexus (SCP) vessel density (VD) and deep capillary plexus (DCP) VD in macular region, radial peripapillary capillary (RPC) VD, optic nerve head (ONH) VD and the foveal avascular zone (FAZ) area.

RESULTS

The samples were gender-balanced, and there were no significant differences in age or gender between the MM and control groups. From the OCTA, all the ONH-VD measurements, except for the peripapillary and superotemporal parameters, were found to be significantly lower in MM patients than in the control group; the same was found for the whole image, inferonasal, superonasal, and superotemporal RPC-VD values; for all the SCP-VD values, except for the inferior hemi and temporal; and for all the DCP-VD values. It was also observed that the deep FAZ area was wider in the MM group than in the control group.

CONCLUSIONS

We detected decreased VD in deep and superficial macular retinal areas, papillary, peripapillary regions, suggesting decreased blood flow and possible ischemia in MM patients. Therefore, obtaining information on ischemia by using a noninvasive and easily measurable method such as OCTA, may be beneficial in terms of follow-up and treatment but this needs to be supported by further, larger studies.

Tractional Retinal Detachment in a Patient With Waldenström's Macroglobulinemia

An 86-year-old man with Waldenström’s macroglobulinemia and a history of acute retinal necrosis (four years ago) presented with reduced visual acuity in his right eye of three days' duration. He developed epiretinal membrane and tractional retinal detachment, which were treated successfully. Epiretinal membrane and tractional retinal detachment usually occur one to two months after the onset of retinitis. In our case, this happened four years after the diagnosis of acute retinal necrosis syndrome, prophylactic vitrectomy, and successful treatment of acute retinal necrosis syndrome in a patient with Waldenström’s macroglobulinemia.

Maculopathy in Patients with Monoclonal Gammopathy of Undetermined Significance

PURPOSE

To describe clinical findings, laboratory values, and treatment response of patients with monoclonal gammopathy of undetermined significance (MGUS) demonstrating neurosensory macular detachment.

DESIGN

Retrospective case series.

PARTICIPANTS

Seven eyes of 4 patients (3 men and 1 woman; age range, 60-81 years) with neurosensory macular detachment, treatment-resistant submacular fluid, and vitelliform material.

METHODS

We retrospectively reviewed the medical and ocular histories, ocular examination findings, retinal imaging, ocular disease course, and laboratory findings in 4 patients with submacular fluid associated with MGUS.

MAIN OUTCOME MEASURES

Description of the macular findings and treatment courses of 4 patients diagnosed with MGUS maculopathy.

RESULTS

Seven eyes of 4 patients demonstrated neurosensory macular detachment with treatment-resistant submacular fluid and vitelliform material. No eyes demonstrated signs of significant hyperviscosity retinopathy. Fluorescein angiography showed no definite leakage in any involved eye. Laboratory evaluation revealed immunoglobulin G MGUS in all 4 patients. All 4 patients were resistant to treatments aimed at resolving the subretinal fluid, including some combination of anti-vascular endothelial growth factor injections, photodynamic therapy, topical dorzolamide, oral dosing of eplerenone or acetazolamide, or some combination thereof. In 3 patients, MGUS underwent malignant transformation 24 to 144 months after diagnosis, in 1 patient to lymphoplasmacytic lymphoma and in 2 patients to multiple myeloma. The fourth patient showed no evidence of malignancy 8 years after diagnosis.

CONCLUSIONS

Submacular fluid without fluorescein leakage and unresponsive to conventional treatment may suggest an underlying immunoproliferative disorder that we have termed monoclonal gammopathy of macular significance. Given the propensity for monoclonal gammopathy of macular significance to transform into malignant disease in our series, serum protein analysis should be considered in patients with neurosensory macular detachment not attributable to known causes.

MULTIMODALITY OCULAR IMAGING IN A CASE REPORT OF HYPERVISCOSITY SYNDROME ASSOCIATED WITH LYMPHOPLASMACYTIC LEUKEMIA: THE IMAGES TELL THE STORY

PURPOSE

To report the clinical course of a patient with ocular manifestations of hyperviscosity syndrome associated with Waldenström macroglobulinemia, and for the first time, video imaging of mobile emboli in the conjunctival and retinal vasculature.

METHODS AND PATIENT

A 60-year-old woman with newly diagnosed Waldenström macroglobulinemia, with no visual complaints was evaluated by the Ophthalmology service for a baseline ocular examination.

RESULTS

At presentation, ocular examination revealed a visual acuity of 20/25 in each eye. Slit lamp examination showed mobile white emboli throughout the conjunctival vasculature of both eyes, which was captured on video. Dilated fundus examination revealed peripheral vascular occlusion along with extensive collateral formation in both eyes and as dilation of vessels at the posterior pole of the left eye. Mobile arterial and venous emboli were also observed in the retinal vasculature, which were captured with slit-lamp color and infrared reflectance video imaging.

CONCLUSION

Hyperviscosity syndrome is a rare circulation sequelae that occurs when blood is thickened secondary to an increase in immunoglobulins or a hyperproliferation of blood components as in bone marrow dyscrasias. The increase in viscosity is plainly observable in the retinal circulation, and this syndrome is often diagnosed based on visual symptoms and fundus examination. We report a patient with Waldenström macroglobulinemia who presented with multiple ocular manifestations of hyperviscosity syndrome despite the absence of visual complaints. Ophthalmologists should be aware that regardless of the lack of any subjective visual changes, ocular findings of hyperviscosity syndrome should prompt quick referral to a Hematology Oncologist for evaluation of other end-organ damage. We also for the first time, provide video documentation of mobile emboli in the conjunctival and retinal vasculature.

Dexamethasone implant for immunogammopathy maculopathy associated with IgA multiple myeloma

Background:

We describe a case where hyperviscosity retinopathy and immunogammopathy maculopathy were the presenting features of IgA multiple myeloma and report the response of maculopathy to intravitreal injection of dexamethasone implants.

Case presentation:

A 56-year-old man presented at the Department of Ophthalmology with the chief complain of reduced vision for the past 10 days in both eyes. Ophthalmic examination revealed central retinal vein occlusion resembling signs with severe macular edema in both eyes with prominent serous macular detachment. After comprehensive evaluation, an IgA type kappa multiple myeloma was diagnosed complicated with hyperviscosity-associated retinopathy and immunogammopathy maculopathy. Patient was treated with multiple sessions of plasmapheresis, systemic chemotherapy, and finally intravitreal implants of dexamethasone with complete restoration of macular edema and serous macular detachment in both eyes. The visual function and the hyperviscosity-associated retinopathy were partially restored.

Conclusion:

Ocular manifestation might be the only presenting sign of a life-threatening disease such as IgA multiple myeloma. A high level of suspicion is required to diagnose and treat such cases promptly and effectively.

Ocular Pathology in Light Chain Deposition Disease

Light-chain deposition disease (LCDD), a rare form of monoclonal gammopathy, is characterized by deposits of amorphous light-chain material, mainly in the kidneys but also in various other organs. Here we present the first report of a light-, electron microscopic and immunohistochemical study of the globes of a patient suffering from LCDD secondary to multiple myeloma. Massive deposits of kappa light chains similar to those typically present in the kidneys were found beneath the basement membrane of the ciliary pigment epithelium, on vessels of the ciliary body, within the collagenous zones of Bruch's membrane, and in the innermost part of the choroid. The choriocapillaris in the macular area was partly obstructed by these deposits, and an exudative retinal detachment was present. Whether this detachment was the consequence of disturbed circulation of the choriocapillaris remains speculative.

OCULAR MANIFESTATIONS OF MONOCLONAL IMMUNOGLOBULIN LIGHT CHAIN DEPOSITION DISEASE

PURPOSE

To demonstrate unusual retinal findings in a patient with progressive renal failure due to idiopathic monoclonal immunoglobulin light chain deposition disease, using multimodal imaging.

METHODS

Observational case report of a 43-year-old white man with renal failure due to light chain deposition disease. His course over 6 years was documented with multimodal imaging including fundus photography, fundus autofluorescence, fluorescein angiography, and spectral domain optical coherence tomography. Additional evaluations included ocular ultrasound, electroretinography, positron emission tomography, serum protein electrophoreses, skeletal surveys to detect osteolytic lesions, and renal, liver, and rectal biopsies in search of amyloid.

RESULTS

The patient's ocular course mirrored the severity of his renal dysfunction for which he required a renal transplant. Changes observed in the native kidney recurred in the transplant 2 years later, as evidenced by immunohistochemistry, revealing thick linear deposits of kappa chains, with no complement, overlying the glomerular basement membrane. The systemic workup was negative for amyloid but showed an overwhelming ratio of kappa to lambda light chains on serum protein electrophoreses and no clinical signs of plasma cell dyscrasias, all consistent with idiopathic light chain deposition disease. The patient presented with a generalized, bilateral "leopard-spot" fundus appearance on fundus autofluorescence, striking globular subretinal deposits on spectral domain optical coherence tomography, and subfoveal subretinal fluid without retinal pigment epithelium detachment or choroidal effusions. The subfoveal fluid did not respond to intravitreal injections of antiangiogenic agents or steroids but resolved after renal transplantation. A temporary posttransplant visual improvement was associated with lessening of the subretinal drusenoid deposits demonstrated by multimodal imaging. The terminal vision deterioration was associated with amorphous, vitelliform-like material deposition and atrophic changes.

CONCLUSION

This case may illustrate a resemblance in the renal glomerulus basement membrane and retinal pigment epithelium-Bruch membrane complex, because the authors observed deposits of excess monoclonal kappa chains manifesting as extracellular, proteinaceous aggregates on the basement membrane of the glomerulus, and striking, globular subretinal deposits that overlay a thickened retinal pigment epithelium-Bruch membrane complex. The ocular lesions' refractoriness to intravitreal treatments could be attributed to the fact that they represent proteinaceous aggregates similar to those documented in the glomeruli. This is the first report of generalized, large, subretinal drusenoid deposits and their course, as documented through multimodal imaging, paralleling the chronology of systemic changes in a patient with light chain deposition disease.

Localized retinal degeneration secondary to Waldenström's macroglobulinemia

A 52-year-old man, treated for Waldenström's macroglobulinemia (WM), continued to experience decreased vision even after 24 months. He was evaluated using multimodal imaging and electroretinography. The retina did not show any hyperviscosity changes but revealed a yellow lesion at macula with atrophic changes causing a pattern on fluorescein angiography similar to a leopard's skin. Optical coherence tomographic imaging revealed uniformly reflective material deposited in the outer retina with degeneration of outer retinal layers. Full-field electroretinography was normal, but multifocal electroretinography revealed reduced foveal responses. This case highlights the degenerative effects of long-standing immunogammopathy maculopathy in WM.

WALDENSTRÖM'S MACROGLOBULINEMIA MASQUERADING AS BIRDSHOT CHORIORETINOPATHY

PURPOSE

To describe Waldenström's macroglobulinemia (WM) as a masquerade syndrome.

METHODS

Case report.

RESULTS

A 59-year-old human leukocyte antigen (HLA)-A29-negative white male presented with a 7-year history of floaters, progressive vision loss, and poor contrast sensitivity along with choroidal lesions suggestive of birdshot chorioretinopathy (BCR). Fluorescein angiography, fundus autofluorescence, and indocyanine green angiography showed multiple areas of hyperfluorescence and hypofluorescence. Electroretinography showed reduced cone and rod responses. Comprehensive workup for infectious, paraneoplastic, and other causes including sarcoidosis was negative at the time. The patient was treated with multiple immunomodulatory agents without any significant improvement. Two years after initial presentation, the patient developed normocytic anemia and high levels of inflammatory markers. Further workup yielded a diagnosis of WM. His choroidal lesions were significantly reduced after treatment with rituximab and bendamustine.

CONCLUSION

We report a case of WM masquerading as BCR. Other indolent diseases should be considered in the differential diagnosis for HLA-A29-negative patients presenting with birdshot-like lesions, especially if they are clinically unresponsive to multiple systemic immunosuppressive agents.

Resolution of bilateral cystoid macular edema and subfoveal serous retinal detachments after treatment with bortezomib in a patient with "smoldering" multiple myeloma

PURPOSE

To describe a case of a patient with multiple myeloma without extraocular end-organ damage but with cystoid macular edema and macular detachments who was treated with bortezomib and dexamethasone. There was a complete resolution of retinal and subretinal fluid and significant improvement of vision.

METHODS

The patient's ocular disease was monitored with visual acuity, dilated fundus examinations, and optical coherence tomography before, during, and after treatment. The patient in this case report was a 43-year-old African American man with a medical history of untreated, "smoldering" multiple myeloma, hypertension, hyperlipidemia who presented to our clinic with progressive painless loss of vision in both eyes over 6 weeks.

RESULTS

Before treatment with bortezomib and dexamethasone, the patient had complaints of confusion, muscle stiffness, joint pain, and 20-lb unintentional weight loss; however, he did not have hypercalcemia, renal insufficiency, anemia, or bone lesions typical of active multiple myeloma. The bilateral cystoid macular edema and subfoveal neurosensory retinal detachments, noted on presentation and confirmed by optical coherence tomography, completely resolved over the course of treatment with bortezomib and dexamethasone.

CONCLUSION

This case of bilateral cystoid macular edema and subfoveal neurosensory retinal detachments is remarkable for both its presentation and response to therapy. The macular edema and macular detachments along with nonspecific complaints of confusion, muscle stiffness, joint pain, and weight loss were the presenting signs and symptoms; signs typically used as guides to initiate treatment for multiple myeloma were not present. Macular edema in the context of paraproteinemia is usually associated with Waldenstrom's macroglobulinemia and has classically been reported as "silent" with respect to fluorescein angiography. Our patient has multiple myeloma and demonstrated leakage on fluorescein angiography. The case is also notable in that there was improvement in visual acuity and restoration of normal macular anatomy after receiving eight cycles of bortezomib and dexamethasone. Bortezomib, a chemotherapeutic agent used to treat refractory or rapidly advancing multiple myeloma, had been used previously to treat similar maculopathy in Waldenstrom disease along with plasmapheresis with resolution of macular edema and improvement in visual acuity. Our patient with multiple myeloma did not require plasmapheresis for significant clinical improvement. Treatment with bortezomib and dexamethasone alone was sufficient to clear the bilateral cystoid macular edema and subretinal fluid.

Immunogammopathy maculopathy associated with Waldenström macroglobulinemia is refractory to conventional interventions for macular edema

PURPOSE

To describe immunogammopathy maculopathy in the setting of Waldenström macroglobulinemia and its lack of response to ocular treatment.

METHODS

Case report of a 65-year-old male patient who presented with a 4-month history of progressive vision loss in the left eye.

RESULTS

Initial ophthalmic examination showed bilateral central retinal vein occlusion with macular edema, including serous macular detachment in the left eye. Serum protein electrophoresis revealed elevated IgM levels, leading to a diagnosis of Waldenström macroglobulinemia. The patient underwent plasmapheresis and systemic chemotherapy with improvement of hyperviscosity retinopathy. However, the macular detachment and edema in the left eye persisted despite repeated intravitreal injections of bevacizumab. Panretinal photocoagulation and intravitreal corticosteroid treatment were also unsuccessful in reversing the maculopathy. A diagnosis of immunogammopathy maculopathy was made, and partial improvement was seen over time after the treatment of Waldenström macroglobulinemia.

CONCLUSION

In the setting of systemic immunogammopathy, conventional treatments for macular edema, including intravitreal anti-vascular endothelial growth factor agents and corticosteroids, may be ineffective. Ocular involvement responds to systemic chemotherapy and plasmapheresis directed against the underlying hematologic malignancy, although this response may be slow and incomplete.

Bilateral macular detachments, venous stasis retinopathy, and retinal hemorrhages as initial presentation of multiple myeloma: a case report

PURPOSE

To present the case of a patient with bilateral macular detachments, venous stasis retinopathy, and retinal hemorrhages as the initial manifestation of multiple myeloma.

METHODS

Case report.

RESULTS

A 59-year-old woman presented with complaints of photopsias and decreased vision and was found to have bilateral macular detachments, venous stasis retinopathy, and retinal hemorrhages. Fluorescein angiography revealed an angiographically silent fundus in both eyes, indicating no fluorescein leakage was found in the macula. Workup revealed multiple myeloma as the cause of the retinal findings.

CONCLUSION

Macular detachment or subretinal fluid, retinal venous dilation or congestion, and retinal hemorrhages may be presenting signs of multiple myeloma.

Waldenström's macroglobulinemia - a review

Waldenström's macroglobulinemia (WM) is a lymphoproliferative disease of B lymphocytes, characterized by a lymphoplasmocytic lymphoma in the bone marrow and by IgM monoclonal hypergammaglobulinemia. It was first described in 1944 by Jan Gösta Waldenström, reporting two patients with oronasal bleeding, lymphadenopathy, anemia, thrombocytopenia, high erythrocyte sedimentation rate and serum viscosity, normal radiography and bone marrow infiltrated by lymphoid cells. The WM is a rare disease with a typically indolent clinical course, affecting mainly individuals aged between 63 and 68 years. Most patients have clinical signs and symptoms related to hyperviscosity resulting from IgM monoclonal gammopathy, and/or cytopenias resulting from bone marrow infiltration by lymphoma. The differential diagnosis with other lymphomas is essential for the assessment of prognosis and therapeutic approach. Treatment of patients with asymptomatic WM does not improve the quality of life of patients, or increase their survival, being recommended, therefore, their follow-up. For the treatment of symptomatic patients, alkylating agents, purine analogs and anti-CD20 monoclonal antibodies are used. However, the disease is incurable and the response to therapy is not always favorable. Recent studies have shown promising results with bortezomib, an inhibitor of proteasomes, and some patients respond to thalidomide. In patients with relapse or refractory to therapy, autologous transplantation may be indicated. The aim of this paper is to describe in detail the current knowledge on the pathophysiology of WM, main clinical manifestations, diagnosis, prognosis and treatment.

Immunogammopathies and acquired vitelliform detachments: a report of four cases

PURPOSE

To describe the nature and evolution of acquired macular detachments in patients with immunogammopathies and to propose a mechanism for their development.

DESIGN

Retrospective observational case series.

METHODS

Three patients with multiple myeloma and 1 with light chain deposition disease were diagnosed with vitelliform macular detachments based on clinical examination, fundus autofluorescence, fluorescein angiography, and optical coherence tomography. These patients were followed over time and their clinical examinations and imaging studies were compared and contrasted.

RESULTS

Three patients (5 eyes) with multiple myeloma and 1 patient (2 eyes) with light chain deposition disease presented with acquired macular yellowish subretinal deposits on funduscopic examination that corresponded to hyperautofluorescent lesions on fundus autofluorescence imaging and subretinal hyperreflective material on spectral-domain optical coherence tomography. One patient (2 eyes) had diffuse serous retinal detachments involving not only the macular region but also the midperiphery of the retina. These acquired macular vitelliform detachments were not associated with signs of hyperviscosity retinopathy in 5 eyes and resolved after successful treatment of the multiple myeloma in 6 eyes.

CONCLUSION

Patients with an immunogammopathy such as multiple myeloma or light chain deposition disease may develop serous elevations of the macula that we classify as acquired vitelliform detachments using multimodal imaging. Appropriate evaluation including serum protein electrophoresis and hematology consultation should be considered in the management of patients with acquired vitelliform detachments of uncertain etiology.

Orbital involvement in Bing-Neel syndrome

Bing-Neel syndrome (BNS) is defined as intracranial involvement of Waldenström macroglobulinemia (WM). Few cases of orbital involvement have been reported. A 51-year-old man with a history of WM developed bilateral orbitopathy and optic neuropathy. Orbital biopsy, cerebrospinal fluid studies, and neuroimaging confirmed the diagnosis of BNS involving the orbital soft tissues, optic nerves, meninges, and cauda equina. The neuro-ophthalmic manifestations resolved after parenteral and intrathecal chemotherapy in addition to autologous stem cell transplantation. The rare neuro-ophthalmic manifestations of BNS may require a multifaceted approach to therapy.

Waldenström macroglobulinemia

In the past 36 months, new developments have occurred both in the understanding of the biology of Waldenström macroglobulinemia (WM) and in therapeutic options for WM. Here, we review the classification, clinical features, and diagnostic criteria of the disease. WM is a B-cell neoplasm characterized by lymphoplasmacytic infiltration of the bone marrow and a monoclonal immunoglobulin M (IgM) protein. The symptoms of WM are attributable to the extent of tumor infiltration and to elevated IgM levels. The most common symptom is fatigue attributable to anemia. The prognostic factors predictive of survival include the patient's age, β2-microglobulin level, monoclonal protein level, hemoglobin concentration, and platelet count. Therapy is postponed for asymptomatic patients, and progressive anemia is the most common indication for initiation of treatment. The main therapeutic options include alkylating agents, nucleoside analogues, and rituximab. Studies involving combination chemotherapy are ongoing, and preliminary results are encouraging. No specific agent or regimen has been shown to be superior to another for treatment of WM. Novel agents such as bortezomib, perifosine, atacicept, oblimersen sodium, and tositumomab show promise as rational targeted therapy for WM.

Bilateral orbital tumor formation and isolated facial palsy in Waldenstrom’s macroglobulinemia

A 32-year-old lady presented with bilateral painful proptosis and left infranuclear facial palsy. She was mildly anemic. Ocular examination revealed a firm non-tender mass in the super lateral quadrant of both orbits. Fine-needle aspiration cytology from the orbital mass showed the presence of lymphoplasmacytoid cells. Bone marrow aspiration also showed the presence of similar cells. An IgM monoclonal gammopathy was seen on serum protein electrophoresis. A diagnosis of Waldenstrom's macroglobulinemia was made on the basis of these findings. Hyperviscosity retinopathy is the most commonly reported ocular abnormality in Waldenstrom's macroglobulinemia. Orbital tumor formation and cranial nerve palsies are rarely reported in this condition. We describe the first case of Waldenstrom's macroglobulinemia presenting as an isolated orbital mass and facial nerve palsy.

Lymphomas involving the eye and the ocular adnexa

PURPOSE OF REVIEW

This review assesses the current status of the different methods used in screening for diabetic retinopathy. This update is particularly timely because the incidence of diabetes is rising rapidly and the number of patients with vision-threatening diabetic retinopathy is increasing.

RECENT FINDINGS

We evaluate the different methods used and their results in improving the delivery of eye care to patients with diabetic retinopathy. In populations with poor access to ophthalmic care, screening techniques such as the nonmydriatic camera used in offices of primary care physicians may be useful in identifying lesions of diabetic retinopathy requiring treatment. One of the limitations is the lack of dilation and cataract formation, which may result in ungradable photographs. Patients with treatable lesions as well as those with ungradable photographs should be referred for comprehensive ocular examination.

SUMMARY

Screening techniques do not replace the eye examination. Ophthalmologists can play an important role in diabetic care apart from treating eye disease. Counseling can be provided to patients regarding the importance of blood glucose and blood pressure control and may motivate patients to achieve strict glucose and blood pressure control.

Homocysteine, MTHFR C677T gene polymorphism, folic acid and vitamin B 12 in patients with retinal vein occlusion

Background

Many available data have suggested that hyperhomocysteinaemia, an established independent risk factor for thrombosis (arterial and venous), may be associated with an increased risk of retinal vein occlusion (RVO).

Aim of the study

To evaluate homocysteine metabolism in consecutive caucasian patients affected by RVO from Northern Italy.

Patients and Methods

69 consecutive patients from Northern Italy (mean age 64.1 ± 14.6 yy) with recent RVO, were tested for plasma levels of homocysteine (tHcy: fasting and after loading with methionine), cyanocobalamine and folic acid levels (CMIA-Abbot) and looking for MTHFR C677T mutation (Light Cycler-Roche) and compared to 50 volunteers, enrolled as a control group.

Results

Fasting levels of tHcy were significantly higher in patients than in controls: mean value 14.7 ± 7.7 vs 10.2 ± 8 nmol/ml. Post load levels were also significantly higher: mean value 42.7 ± 23.7 vs 30.4 ± 13.3 nmol/ml; Total homocysteine increase was also evaluated (i.e. Δ-tHcy) after methionine load and was also significantly higher in patients compared to control subjects: mean Δ-tHcy 27.8 ± 21.5 vs 21.0 ± 16 nmol/ml (normal value < 25 nmol/ml). Furthermore, patients affected by RVO show low folic acid and/or vitamin B12 levels, although differences with control group did not reach statistical significance. Heterozygous and homozygous MTHFR mutation were respectively in study group 46% and 29% vs control group 56% and 4%.

Conclusion

our data confirm that hyperhomocysteinaemia is a risk factor for RVO, and also that TT genotype of MTHFR C677T is more frequently associated with RVO: if the mutation per se is a risk factor for RVO remains an open question to be confirmed because another study from US did not reveal this aspect.

Hyperomocysteinemia is modifiable risk factor for thrombotic diseases. Therefore, a screening for tHcy plasma levels in patients with recent retinal vein occlusion could allow to identify patients who might benefit from supplementation with vitamins and normalization of homocysteine levels, in fasting and after methionine load.

Diagnosis and management of Waldenstrom's macroglobulinemia

PURPOSE

To review the diagnostic criteria, prognostic factors, response criteria, and treatment options of patients with Waldenstrom's macroglobulinemia (WM).

METHODS

A review of published reports was facilitated by the use of a MEDLINE computer search and by manual search of the Index Medicus.

RESULTS

WM should be regarded as a distinct clinicopathologic entity and confined to those patients with lymphoplasmacytoid lymphoma who have demonstrable serum immunoglobulin M monoclonal protein. Treatment decisions should rely on specific clinical and laboratory criteria. Initiation of therapy should not be based on serum monoclonal protein levels per se. The three main choices for systemic primary treatment of symptomatic patients with WM include alkylating agents (chlorambucil), nucleoside analogs (fludarabine and cladribine), and the monoclonal antibody rituximab. There are no data from prospective randomized studies to recommend the use of one first-line agent over another, although consideration of a patient's candidacy for autologous stem-cell transplantation (ASCT) should be taken into account to avoid stem cell-damaging agents. There are preliminary data to suggest that combinations of nucleoside analogs and alkylating agents with or without rituximab may improve response rates at the expense of higher toxicity.

CONCLUSION

WM is a distinct low-grade lymphoproliferative disorder. When therapy is indicated, alkylating agents, nucleoside analogs, and rituximab are reasonable choices. Several factors, including the presence of cytopenias, need for rapid disease control, candidacy for ASCT, age, and comorbidities, should be taken into consideration when choosing the most appropriate primary treatment.

Ophthalmic manifestations of multiple myeloma

PURPOSE

To describe ophthalmic manifestations in a series of patients with multiple myeloma (MM) and review the literature.

DESIGN

Retrospective case series.

METHODS

Review of all cases with ophthalmic manifestations of MM seen at the Department of Ophthalmology, Royal Adelaide Hospital, between 1987 and 2002.

RESULTS

Of all patients with MM who were managed at the Royal Adelaide Hospital in the study period, only 8 were referred to the Ophthalmology Department with ophthalmic manifestations. Five males and 3 females with a mean age of 61.25 years (range 42-78) who exhibited ophthalmic manifestations were studied. Six patients (75%) had known MM at the time of their ophthalmic evaluation. Four patients (50%) had neuro-ophthalmic symptoms resulting in diplopia or visual disturbances. Three patients (37.5%) presented with orbital involvement and 1 (12.5%) with hyperviscosity retinopathy. Five patients (62.5%) died within 2 months of their ophthalmic presentation.

CONCLUSION

Ophthalmic manifestations of MM are uncommon and diverse. They may appear at the initial presentation of the disease or occur late in the disease process. Awareness of the possible manifestations may lead to an earlier diagnosis and have a positive influence on the disease course.

Extranodal marginal zone B-cell lymphoma of the lacrimal gland associated with crystal-storing histiocytosis

OBJECTIVE

Crystal-storing histiocytosis (CSH) is a very rare immunoglobulin (Ig) deposition disorder that can be associated with B-cell neoplasms as well as some reactive Ig-secreting lymphoproliferative disorders. This article reports the clinical, histopathologic, and molecular biologic findings of CSH in association with an extranodal marginal zone lymphoma (EMZL) of the lacrimal gland.

DESIGN

Interventional case report with clinicopathologic correlation.

INTERVENTION

Treatment consisted of conjunctival and orbital biopsies, as well as low-dose radiation of the left orbit.

METHODS

Histopathologic findings of the conjunctival and orbital biopsies were compared. Further, extensive immunohistochemistry, polymerase chain reaction (PCR) for the detection of Ig heavy chain (IgH) gene rearrangement, Gene Scan analysis, and DNA sequencing were performed on all tissues.

RESULTS

The tumor manifestations in the specimens demonstrated a similar morphologic and immunophenotypic characteristics consistent with the diagnosis of EMZL. Immunoglobulin H PCR and Gene Scan analysis showed B cells derived from the same clone. In association with the orbital EMZL were large accumulations histiocytes filled with refractile crystals, consistent with the diagnosis of CSH.

CONCLUSIONS

The current case describes an EMZL of the lacrimal gland appearing 5 years after excision and low-dose radiation of a conjunctival lymphoma. The orbital recurrence was associated with surrounding CSH, a rare Ig storage disorder more often reported in patients with multiple myeloma or lymphoplasmacytic lymphoma or immunocytoma. Ophthalmic pathologists should be aware of the diagnosis when reviewing orbital biopsies, because difficulties may arise when the crystal-storing macrophages occupy more tissue space than the Ig-secreting cells or when they resemble cell types such as rhabdomyoblasts.

Unusual immunogammopathy maculopathy

PURPOSE

To describe an unusual maculopathy in patients with serum immunogammopathies.

DESIGN

Retrospective observational small case series.

PARTICIPANTS

Three patients derived from the clinical retina practices of the authors were noted to have unusual maculopathy.

METHODS

Each patient underwent fluorescein angiography and serum laboratory evaluation.

MAIN OUTCOME MEASURE

Findings on fluorescein angiography.

RESULTS

An unusual and atypical macular detachment with or without subretinal precipitates or fundus signs of serum hyperviscosity, such as retinal hemorrhages and dilated retinal veins, may be observed in patients with immunogammopathies such as multiple myeloma, Waldenström's macroglobulinemia, and benign polyclonal gammopathy. Fluorescein angiography shows macular hypofluorescence with no evidence of retinal vascular or retinal pigment epithelial leakage within the macular elevation.

CONCLUSIONS

Patients with atypical unilateral or bilateral macular detachment may be afflicted with a serum immunogammopathy such as multiple myeloma or Waldenström's macroglobulinemia. Diagnostic serum protein electrophoresis and hematology consultation should be considered.