Subretinal fluid accumulation in a patient with polycythemia vera after receiving a prostaglandin I2 analogue treatment

Purpose

To report a case of polycythemia vera (PV) with subretinal fluid accumulation after the administration of prostaglandin I2 (PGI2) analogue.

Observations

A 57-year-old woman diagnosed as having PV was referred to our department for the evaluation of severe metamorphopsia in the left eye, which gradually progressed after the initiation of oral administration of PGI2 mimetics. At the first visit, the patient's best-corrected visual acuities (BCVAs) were 20/20 OD and 20/30 OS. Fundus examination and optical coherence tomography revealed the presence of subretinal fluid (SRF) in the left eye and multiple serous pigment epithelial detachments (PEDs) in both eyes. Fluorescein angiography revealed central serous chorioretinopathy (CSC)-like lesions, consisting of dye pooling corresponding to the PEDs in both eyes and dye leakage in the left eye. Indocyanine green angiography and laser speckle flowgraphy revealed dilated choroidal veins and reduced choroidal blood flow, respectively. The central choroidal thickness (CCT) measured at the first visit showed a relatively thickened choroid in the left eye. Laboratory data showed mild pancytosis. The patient was diagnosed as having CSC associated with a background of PV, presumably triggered by the PGI2 analogue. One month after cessation of drug administration, the patient's BCVA improved, the CCT slightly decreased, and serous retinal detachment and PED disappeared in the left eye.

Conclusions and importance

Our case of PV presenting with CSC-like lesions after PGI2 analogue administration indicates the possible risk of SRF accumulation by PGI2 analogues in patients with PV.

Monoclonal gammopathy of ocular significance (MGOS) - a short survey of corneal manifestations and treatment outcomes

Monoclonal gammopathy of ocular significance (MGOS) is a rare subset of monoclonal gammopathy of clinical significance occurring secondary to plasma cell disorders and causing ocular manifestations. We identified 23 patients with paraproteinemic keratopathy (PPK) in the setting of monoclonal gammopathy of unknown significance (MGUS, 10), smoldering multiple myeloma (SMM, 3) or multiple myeloma (MM, 10). Many of these patients with PPK (11/23) presented decreased vision. All patients with MM and 40% of those with other diagnoses such as SMM and MGUS received systemic therapy with or without autologous stem cell transplantation. Four eyes of four patients were treated by penetrating keratoplasty. In most cases, neither ocular nor hematologic treatment afforded a durable improvement in the visual acuity (recurrence after a median of 11 months), despite initial responses. Further studies will be required to determine the optimal strategy to treat and prevent the relapse of ocular symptoms in patients with PPK.

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.

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.

Paraproteinemic maculopathy

PURPOSE

Paraproteinemia relates to monoclonal gammopathy-producing pathologic antibodies with serous macular detachment being an uncommon ocular manifestation. We ascertained the clinical course of maculopathy in paraproteinemia and investigated the effect of various therapeutic methods on the resolution of subretinal deposits.

DESIGN

Multicenter, retrospective, observational case series.

PARTICIPANTS

The records of patients with paraproteinemia with optical coherence tomography (OCT) documentation of serous macular detachment were reviewed.

METHODS

Data collection included coexisting morbidity, rheology data (immunoglobulin level, hematocrit, and blood viscosity), clinical examination results, and OCT findings.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), height and basal area of the serous macular detachment, and systemic versus local therapies.

RESULTS

A total of 33 cases were collected: 10 new and 23 previously reported in the literature. Diabetes was present in 7 patients, systemic hypertension in 9 patients, and anemia in 18. Mean initial immunoglobulin level was 6497 mg/dl, and mean serum viscosity was 5.5 centipoise (cP). Mean logarithm of the minimum angle of resolution initial vs. final BCVA was 0.55 (Snellen equivalent, 20/71) vs. 0.45 (20/56) in the right eye and 0.38 (20/48) vs. 0.50 (20/63) in the left eye. After mean follow-up of 7 months (range, 0-51 months). Systemic therapies included plasmapheresis (18), chemotherapy (30), blood transfusions (2), transplantation of progenitor hematopoietic cells (2), and oral rituximab (10). Immunoglobulin levels normalized in 8 patients and were unchanged in 1 after plasmapheresis, chemotherapy, or both. Ocular therapy in 8 patients included vitrectomy (1), laser photocoagulation (4), intravitreal bevacizumab (5), intravitreal triamcinolone (2), intravitreal dexamethasone implant (1), intravitreal rituximab (1), and sub-Tenon corticosteroid (1). The maculopathy resolved partially or completely in 17 patients and worsened or remained unchanged in 14 patients over median follow-up of 7 months. Maculopathy was unilateral in 9 cases and occurred at a lower initial immunoglobulin level in diabetics. There was a positive correlation between area of the detachment and serum viscosity.

CONCLUSIONS

Paraproteinemic maculopathy can be unilateral. Decreasing the blood immunoglobulin level is the primary goal of therapy for paraproteinemic maculopathy, and this can be achieved by a systemic route. Coexisting diabetes facilitates leakage of immunoglobulins at lower levels than in nondiabetics.

Atypical unilateral maculopathy associated with acute exudative polymorphous vitelliform maculopathy-like yellowish deposits

PURPOSE

To report a case of atypical unilateral maculopathy associated with acute exudative polymorphous vitelliform maculopathy-like yellowish deposits.

METHODS

Observational case report of one patient.

RESULTS

A 52-year-old man presented with reduced vision in the left eye. Findings resembling acute exudative polymorphous vitelliform maculopathy were noted with ophthalmoscopy, fluorescein angiography, and optical coherence tomography. Funduscopic examination revealed an exudative macular detachment with yellowish subretinal deposits inferior to the fovea. On fluorescein angiography, the perifoveal lesions were minimally hyperfluorescent, with no abnormal fluorescence in the central macula. The subretinal deposits were found to be hyperautofluorescent on fundus autofluorescence imaging. Optical coherence tomography confirmed a serous detachment of the retina with intraretinal cystic spaces. The right eye did not show any abnormalities except for an epiretinal membrane.

CONCLUSION

We describe a case of atypical unilateral maculopathy associated with acute exudative polymorphous vitelliform maculopathy-like yellowish deposits.

Ocular findings in a patient with Castleman's disease before and after treatment with immunosuppression and plasmapheresis

A 12-year-old girl with a 3-month history of epistaxis and Castleman's disease presented with blurred vision in both eyes for 2 weeks. Indirect ophthalmoscopy revealed a blurred optic disc margin, venous engorgement and tortuosity, intraretinal hemorrhages and cotton wool spots, and serous detachment of the neurosensory retina in the posterior pole of each eye. Fluorescein angiography and laboratory tests revealed abnormalities consistent with the clinical examination. Six months following institution of immunosuppressive treatment, cryoglobulin levels decreased and visual acuity and funduscopic abnormalities were markedly improved. However, a few microaneurysms, retinal hemorrhages, and venous engorgement and tortuosity persisted. One month after the cessation of immunosuppressive treatment, symptoms related to the hyperviscosity syndrome recurred and the patient was treated with one session of plasmapheresis. One month after the plasmapheresis, the patient's symptoms resolved, laboratory values were normal, visual acuity was 20/15 in both eyes, and the funduscopic examination of each eye was unremarkable.

Systemic disorders associated with detachment of the neurosensory retina and retinal pigment epithelium

Serous detachment of the neurosensory retina and of the retinal pigment epithelium is a rare event in the course of systemic disease. Retinal pigment epithelial detachments usually occur in association with serous retinal detachments, although, in some cases, they also may be observed as an isolated finding. In a number of patients, the initial pigment epithelial detachment may be at the origin of a later-developing serous detachment. Diagnosis of a serous detachment still is made clinically, although optical coherence tomography recently has allowed the detection of clinically occult serous elevations of the retina. The underlying mechanisms of subretinal exudation are thought to include choroidal vascular perfusion and permeability changes, which result in increased choroidal interstitial fluid with further extension into the subretinal space. These changes are mostly incurred in the course of systemic inflammatory and infectious diseases such as sarcoidosis, Vogt-Koyanagi-Harada disease, and cytomegalovirus infection, and also in association with disorders resulting in the acute occlusion of the precapillary choroidal arterioles by fibrin-platelet thrombi. Collagen vascular diseases, disorders associated with disseminated intravascular coagulopathy, and malignant hypertension fall into this category. Hypercortisolism, renal disease, and, very rarely, malignant disease also have been implicated in the development of serous retinal detachment. Therapy of the serous detachments consists primarily of treating the underlying systemic disease.