Intravitreal bevacizumab: a viable treatment for bilateral central retinal vein occlusion with serous macular detachment secondary to Waldenström macroglobulinaemia

Immunogammopathy Maculopathy Secondary to Waldenström's Macroglobulinemia Complicated With Diabetic Retinopathy: A Case Report and Literature Review

In Waldenström's Macroglobulinemia (WM), increased immunoglobulin M causes various signs and symptoms. It sometimes presents with macular edema. A 65-year-old WM patient with a five-year history of diabetes mellitus was evaluated for ocular complications. Fundus examination and optical coherence tomography showed retinal changes consistent with non-proliferative diabetic retinopathy and foveal detachment with intraretinal cysts in the right eye, suggesting diabetic macular edema. However, on fluorescein angiography, there was no leakage over the area of foveal detachment, which led to the diagnosis of immunogammopathy maculopathy secondary to WM for macular edema and foveal detachment. The patient's ocular manifestation remained unchanged through a follow-up period of 11 months without therapeutic interventions. Immunogammopathy maculopathy, a rare ocular manifestation of monoclonal gammopathy, demands differentiation from other causes of macular edema in WM patients. The present case highlights the importance of fluorescein angiography, or silent macula, in diabetic patients to distinguish immunogammopathy maculopathy from diabetic macular edema.

Hyperviscosity Retinopathy Due to Waldenström Macroglobulinemia: A Case Report and Literature Review

Purpose:

This case report describes a case of hyperviscosity retinopathy secondary to the rare systemic hematologic malignant neoplasm Waldenström macroglobulinemia.

Methods:

Fundus photography, fluorescein angiography, optical coherence tomography (OCT), and OCT angiography were used as imaging modalities to characterize this pathology.

Results:

A 51-year-old man presented with hyperviscosity retinopathy and uniquely angiographically silent serous macular detachment. Over a 6-month period, he was treated with systemic and local therapies with little improvement in the hyperviscosity retinopathy, serous macular detachments, or visual acuity.

Conclusions:

Hyperviscosity retinopathy secondary to Waldenström macroglobulinemia presents a challenge to treating ophthalmologists given its rarity and the range of treatment responses described in the literature. Our patient’s lack of response to antivascular endothelial growth factor and normal findings in OCT angiography and fluorescein angiography suggested the mechanism of subretinal fluid accumulation was not vascular endothelial growth factor mediated. Visual prognosis was guarded.

Optical coherence tomography angiography characteristics in Waldenström macroglobulinemia retinopathy: A case report

BACKGROUND

Waldenström macroglobulinemia (WM) is a distinct clinicopathologic entity characterized by the infiltration of the bone marrow by clonal lymphoplasmacytic cells that produce monoclonal immunoglobulin M (IgM) in the blood, and patients may present with symptoms related to the infiltration of the hematopoietic tissues or the effects of monoclonal IgM in the blood. Funduscopic abnormalities were noted in some of the patients due to hyperviscosity or other retinal lesions. Optical coherence tomography angiography (OCTA) as a non-invasive imaging tool can give qualitative and quantitative information about the status of retinal and choroidal vessels, which might be useful for diagnosing patients with WM-associated retinopathy.

CASE SUMMARY

The patient was a 67-year-old man who presented with sudden visual disturbance in both eyes. Ophthalmic tests showed that best corrected visual acuity (BCVA) for this patient was 20/100 in the right eye and 20/1000 in the left eye. Fundus examination, optical coherence tomography (OCT), and OCTA revealed substantial bilateral optic disc edema, dilated and tortuous retinal veins, and diffuse intraretinal blot hemorrhages and edema which were consistent with bilateral central retinal vein occlusion (CRVO). Meanwhile, remarkable bilateral serous macular detachments (SMD) were noticed on OCT. Systemic examinations showed that the patient had anemia and extremely high level of monoclonal IgM and infiltration of clonal lymphoplasmacytic cells in bone marrow. The diagnosis of WM with hyperviscosity and retinopathy was made based on the clinical manifestation and laboratory findings. He was subsequently treated with intravitreal ranibizumab injection, plasmapheresis, and bortezomib plus rituximab with dexamethasone. Six months after treatments, the central macular volume decreased by 16.1% in the right eye and 28.6% in the left eye on OCT, and the patient’s BCVA was improved to 20/60 in the right eye and 20/400 in the left eye. Very good partial response was obtained after systemic treatment.

CONCLUSION

WM may affect visual function and present as bilateral CRVO. OCTA can show characteristic changes in both retina and choroid vasculatures, which might be of great value for diagnosing or following patients with WM retinopathy. Intravitreal anti-vascular endothelial growth factor treatment combined with systemic therapy might be beneficial for WM patients with retinopathy (SMD and CRVO).

UNUSUAL SEROUS RETINAL DETACHMENT IN A PATIENT WITH WALDENSTROM MACROGLOBULINEMIA: A CASE REPORT

BACKGROUND/PURPOSE

To report an unusual appearance of severe bilateral serous detachments in a patient with Waldenstrom macroglobulinemia.

METHODS

A case report of a Fifty-six-year-old female patient with Waldenstrom macroglobulinemia.

RESULTS

A patient with Waldenstrom macroglobulinemia presented with serous retinal detachments at the time of diagnosis with Waldenstrom. The patient's IgM levels remained abnormally elevated in the initial stages of her disease course, leading to dramatic ocular findings and images on optical coherence tomography. Chemotherapy was initiated and IgM levels slowly declined, with some improvement in macular fluid as IgM normalized.

CONCLUSION

Waldenstrom macroglobulinemia may lead to dramatic retinal pathology if IgM levels remain elevated. Prompt chemotherapy and reduction of immunoglobulin levels should be undertaken to preserve retinal architecture.

Bilateral simultaneous central retinal vein occlusion in hyperviscosity retinopathy treated with systemic immunosuppressive therapy only

PURPOSE

To describe the clinical presentation and imaging features of a patient presenting with bilateral central retinal vein occlusion (CRVO), who was subsequently diagnosed with hyperviscosity retinopathy due to B cell lymphoproliferative disease, and had a good response to systemic immunosuppressive therapy.

OBSERVATIONS

A clinical case report of an 87-year-old woman who presented with bilateral CRVO. Visual acuity, clinical examination, spectral domain optical coherence tomography (SD-OCT), color fundus photography and systemic evaluation were obtained. Ocular examination at presentation revealed bilateral CRVO, and OCT examination revealed significant central macular edema bilaterally. Six months after the diagnosis of hyperviscosity retinopathy and administration of systemic cyclophosphamide immunosuppressive therapy for B cell lymphoproliferative disease, most of the retinal hemorrhages resolved and partial resolution of the macular edema in the left eye was observed.

CONCLUSION AND IMPORTANCE

This case describes the association between bilateral simultaneous CRVO and hyperviscosity. Under unique circumstances our patient received systemic therapy alone, without plasmapheresis. Although only limited therapy was applied, she didn't have deterioration or recurrent events; she had a small improvement in her macular edema and a significant improvement in her systemic functional state as well as reduction in her monoclonal IGM level.

Retinal vein thrombosis and risk of occult cancer: A nationwide cohort study

Background

Retinal vein thrombosis has in case reports been reported a clinical sign of cancer, especially hematological cancer. However, it is unclear whether retinal vein thrombosis is a marker of underlying cancer, as is the case for deep venous thrombosis and pulmonary embolism. We investigated the risk of occult cancer in patients with retinal vein thrombosis.

Methods

A nationwide population‐based cohort study in Denmark on all patients diagnosed with a retinal vein thrombosis during 1994 and 2013. The main outcome measures were any cancer and site‐specific cancers <6 months, 6‐12 months, and 5 years following a retinal vein thrombosis diagnosis, as registered in the Danish Cancer Registry and the National Pathology Registry. We calculated the absolute cancer risk and computed standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) for cancer within <6 months, 6‐12 months, and 5 years following a retinal vein thrombosis diagnosis.

Results

Among 9589 patients with retinal vein thrombosis, we observed 1514 cancer cases. The risk of any cancer was 1.2% <6 months and 28.8% after 5 years. The <6 months SIR was 1.20 (95% CI 0.99‐1.44), 6‐12 months SIR was 1.15 (95% CI 0.94‐1.39), and the 5 years’ SIR was 1.08 (95% CI 1.03‐1.14). Stratification by age, gender, calendar year, and Charlson Comorbidity Index score did not change overall cancer risk estimates.

Conclusion

Retinal vein thrombosis was not an important clinical marker for occult cancer. An extensive diagnostic cancer workup does not appear warranted for retinal vein thrombosis patients.