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

Bilateral Exudative Retinal Detachments and Panuveitis in a Patient with Multiple Myeloma

PURPOSE

To report a case of bilateral exudative retinal detachments and panuveitis in a patient with multiple myeloma (MM).

CASE REPORT

A 54-year-old patient with non-proliferative diabetic retinopathy was referred with blurred vision and scotomas in both eyes (OU). Three months prior to the onset of ocular symptoms, he was diagnosed with systemic MM and was receiving chemotherapy. Clinical examination revealed best-corrected visual acuities of 20/80 OU, rare anterior chamber cell, 2+ vitreous cell, diffuse intraretinal hemorrhages, and exudative retinal detachments (RD). Optical coherence tomography of the macula showed central subretinal fluid with cystic intraretinal fluid OU. The findings were consistent with panuveitis and exudative RD in the setting of MM. He reported symptomatic improvement after plasmapheresis and oral prednisone initiation.

CONCLUSION

Extensive, bilateral exudative RD and panuveitis are rare but potentially sight-threatening findings in patients with MM.

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.

Uncommon Presentations of Multiple Myeloma

Multiple myeloma is a rare malignancy that exhibits a wide range of possible clinical presentations. In recent years, with the advent of stem cell transplantation, the prognosis of patients with multiple myeloma has been increasing. We searched the literature for reports of atypical myeloma presentations to aid clinicians in formulating differential diagnoses and to increase the number of cases diagnosed early. There have been a number of reports of early ocular symptoms, including, but not limited to, proptosis, optic neuropathy, vision loss, retinal hemorrhage, and detachment. Neurological presentations included cranial nerve palsies, vertigo related to cerebellar involvement, and diabetes insipidus related to pituitary involvement. Among gastrointestinal manifestations, there are a number of reports of multiple myeloma presenting as acute and chronic pancreatitis. Mesenteric ischemia due to amyloidosis, acute abdomen, and hepatosplenomegaly were also among reported presentations. When it comes to renal involvement, while acute renal failure and proteinuria are typical, there are reports of patients presenting with both nephritic and nephrotic forms of glomerular disease, as well as end-stage renal disease requiring dialysis. We believe that it is essential for clinicians to keep reporting atypical multiple myeloma presentations and consider it as a possible diagnosis in a patient with serious, atypical symptoms.

Multiple myeloma masquerading as diabetic macular oedema

A 58-year-old man, a known diabetic and hypertensive for 5 years was presented to us with a drop in reading vision in both eyes of 2 months duration. His best-corrected visual acuity was 6/24, N36 in both eyes. Fundus findings revealed moderate non-proliferative diabetic retinopathy with bilateral diffuse macular oedema. When conventional therapy with intravitreal ranibizumab did not alter the clinical picture, we looked into the differential diagnosis of bilateral persistent macular detachments and investigated further. Haematological tests revealed severe anaemia with pancytopenia, which prompted further investigations including a bone marrow biopsy confirming a diagnosis of multiple myeloma. Chemotherapy gradually caused resolution of the macular detachments at 8 months follow-up. This report illustrates that a high index of suspicion regarding systemic condition is required in certain cases presenting as diabetic macular oedema, but not responding to the conventional treatment.