Visual loss caused by corneal crystals in myeloma: rapid improvement and plasma exchange and chemotherapy

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.

Characterization of corneal deposition keratopathy in the setting of blood cell dyscrasia and a minimally invasive technique to clear the cornea in a single case

Purpose

To report 3 cases of corneal protein deposition occurring in association with systemic disease, with one case demonstrating a novel technique for clearing corneal deposits.

Observations

Three patients presented with corneal deposits associated with systemic disease. Corneal involvement was noted prior to diagnosis of systemic disease in two patients, leading to subsequent diagnosis of multiple myeloma or monoclonal gammopathy of undetermined significance. OCT revealed protein deposition at various corneal levels, including at different stromal depths in the two cases of multiple myeloma. A novel technique of posterior endothelial scraping was performed in one case with deep stromal deposits, leading to significant corneal clearing.

Conclusions and Importance

This case series demonstrates that recognition of corneal deposits may precede the diagnosis of systemic disease. It incorporates the use of anterior segment OCT to characterize corneal deposits, and demonstrates a novel surgical technique for clearing certain types corneal deposits.

Corneal Opacity Leading to Multiple Myeloma Diagnosis: A Case Report and Literature Review

Patient: Female, 54

Final Diagnosis: Multiple myeloma

Symptoms: A 9-month history of blurred vision

Medication: Systemic chemotherapy with vincristine • cyclophosphamide • dexamethasone

Clinical Procedure: Multiple myeloma patient presenting with corneal opacity and blurred vision as chief complaint

Specialty: Ophthalmology and Hematology

Unusual Manifestations of Monoclonal Gammopathy: I. Ocular Disease

Essential monoclonal gammopathy is usually an asymptomatic condition, the characteristics of which have been defined over approximately 70 years of study. It has a known population-attributable risk of undergoing clonal evolution to a progressive, symptomatic B-cell neoplasm. In a very small fraction of patients, the monoclonal immunoglobulin has biophysical characteristics that can lead to tissue deposition syndrome (e.g. Fanconi renal syndrome) or, by chance, have characteristics of an autoantibody that may inactivate critical proteins (e.g. acquired von Willebrand disease). In this report, we describe the very uncommon forms of ocular injury that may accompany essential monoclonal gammopathy, which include crystalline keratopathy, crystal-storing histiocytosis, hypercupremic keratopathy, and maculopathy. The first three syndromes result from uncommon physicochemical alterations of the monoclonal immunoglobulin that favor crystallization or exaggerated copper binding. The last-mentioned syndrome is of uncertain pathogenesis. These syndromes may result in decreased visual acuity. These ocular findings may lead, also, to the diagnosis of monoclonal gammopathy.

Immunotactoid keratopathy: a clinicopathologic case report and a review of reports of corneal involvement in systemic paraproteinemias

Corneal deposits in association with paraproteinemias have been well described in the ophthalmic literature. Recent reports in the renal literature have described immunotactoid deposition associated with glomerulopathy-organized microtubular deposits of IgGkappa that measured 32-50 nm in diameter on renal biopsies. We present a case of corneal immunotactoid deposition in the setting of chronic lymphocytic leukemia and review previous reports of corneal deposition in the setting of systemic paraproteinemia, highlighting the etiology, differential diagnosis, prognosis, and treatment of corneal involvement. We propose the use of the term immunotactoid keratopathy to describe corneal IgGkappa deposits appearing as tubular, electron-dense, crystalloid deposits with a central lucent core on electron microscopy and suggest that these patients undergo directed systemic workup to evaluate for potential etiologies of their systemic paraproteinemia. To illustrate the spectrum of paraprotein deposition in the cornea, and to emphasize the importance of ophthalmic evaluation in the setting of systemic paraproteinemias, we include a case of a 44-year-old man with immunoprotein corneal deposition who was subsequently diagnosed with multiple myeloma.

Corneal Intrastromal Gatifloxacin Crystal Deposits After Penetrating Keratoplasty

BACKGROUND

An 85-year-old man developed faint crystallike white precipitates in the mid peripheral stroma of his left cornea 3 weeks after undergoing penetrating keratoplasty. The patient had been initially treated with 1% prednisolone acetate ophthalmic suspension and 0.3% gatifloxacin eyedrops to his left eye from the first day postoperatively. Three weeks later, the precipitates were more numerous, larger, and diffuse in distribution. Gatifloxacin was discontinued and substituted with a neomycin-polymixin B-dexamethasone ophthalmic ointment.

METHODS

A detailed history, physical examination, laboratory workup, and tandem scanning confocal microscopy were performed.

RESULTS

Tandem scanning corneal confocal microscopy confirmed the presence of crystals in the cornea.

CONCLUSIONS

Gatifloxacin, a fourth-generation fluoroquinolone, can cause intrastromal macroscopic crystalline deposits through a compromised corneal epithelium, similar to what has been described for ciprofloxacin, a second-generation fluoroquinolone.

Keratopathy of multiple myeloma masquerading as corneal crystals of ocular cystinosis

We describe a 49-year-old woman in whom ocular cystinosis was diagnosed on the basis of a routine eye examination 12 years previously. Conjunctival biopsy was reported to support the diagnosis. The patient described photophobia for the past 5 years and reported a 2-fold increase in her serum IgG level for the past 12 years. On ophthalmic examination, corneal crystals were evident in the epithelium and superficial stromal layers, rather than throughout the corneal epithelium and the entire stroma as in ocular cystinosis. The patient's serum protein level was elevated at 8.7 g/dL; protein electrophoresis showed an elevated gamma-globulin peak, and the IgG level was twice that of normal at 2820 mg/dL. Bone marrow biopsy confirmed the diagnosis of multiple myeloma. This case illustrates that multiple myeloma can mimic corneal findings of cystinosis.

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.

Paraproteinemic corneal deposits in plasma cell myeloma

We treated two patients who had IgG-kappa-light chain monoclonal gammopathy with partially crystalline and partially amorphic corneal deposits. Impairment of vision made keratoplasty necessary for each patient. Histologic examination of the corneal specimens showed deposits that stained positively for Masson's trichrome in all corneal cells. Immunohistochemical tests identified these deposits as IgG-kappa-light chain immunoglobulin fragments. Electron microscopy showed intracellular, rhomboid-shaped deposits enveloped by a membrane. The same deposits appeared in the conjunctival epithelium, within subconjunctival fibrocytes, and in the plasma cells of the bone marrow. Immunoelectrophoresis showed IgG-kappa-light chain fragments in the blood serum, the lacrimal film, and the aqueous humor. This suggests that the intracellular immunoglobulin fragments may have entered the corneal and conjunctival epithelium by way of the lacrimal film, the keratocytes by way of the corneo-scleral limbus vasculature, and the endothelial cells from the aqueous humor.

Therapeutic plasmapheresis and protein A immunoadsorption in malignancy: a brief review

Plasmapheresis is being used with considerable frequency in the management of malignant and non-malignant disorders. More recently, staphylococcal Protein A immunoadsorption has been employed in similar clinical situations. In patients with malignancy, plasmapheresis has been shown to produce alterations in plasma proteins, decrease circulating immune complexes, remove "specific" and "non-specific" blocking factors, change immune reactivity, and affect monocyte function. Partial responses have been reported in a small number of patients with carcinoma of lung, colon, and breast following plasmapheresis. In addition, there are reports of favorable responses in patients with melanoma, head and neck tumors, lymphomas, leukemias, and Kaposi's sarcoma in acquired immune deficiency. All these responses were partial and brief, and the treatment did not alter the course of the disease. Plasmapheresis has been useful in the management of hyperviscosity and occasionally of paraneoplastic syndromes. It may also have a role in the treatment of thrombotic thrombocytopenic purpura associated with mitomycin-C therapy. Protein A immunoadsorption, by which circulating immune complexes are selectively removed, can activate the complement system, increase blastogenic responses, and increase the natural killer cell activity. It has been shown to produce partial responses in breast and colon cancer, as well as Kaposi's sarcoma in acquired immune deficiency. It may have a useful role to play in the management of mitomycin-C-associated thrombotic thrombocytopenic purpura. Both plasmapheresis and Protein A immunoadsorption should be considered investigational interventions at this time. Toxicity of plasmapheresis, though uncommon, can be serious and may rarely be fatal. Toxicity of Protein A immunoadsorption is mild, consisting mainly of influenza-like symptoms and rash.

Corneal subepithelial monoclonal kappa IgG deposits in essential cryoglobulinaemia

A 60-year-old man suffering from photophobia and visual disturbances was found to have bilateral superficial corneal grey-white gelatinous deposits. An abnormal cold-precipitable serum component was found and characterised as homogeneous IgG-kappa immunoglobulin. Corneal immunohistochemical examination revealed subepithelial IgG-kappa deposits, focally replacing Bowman's layer. The patient underwent superficial keratectomy in both eyes with satisfactory visual results.

Determination of the nature of corneal crystals by specular microscopy

The use of the specular microscope as a noninvasive in vivo method of identifying cholesterol crystals in two cases of crystalline corneal deposits is described. This illustrates the advantage of using the specular microscope under living conditions with a much higher magnification than is obtained with the slit lamp. Attention is drawn to the wider applications of this method.

Paraproteinemic crystalline keratopathy

Paraproteinemic crystalline keratopathy is an uncommon complication of multiple myeloma and other plasma cell dyscrasias. A case of 16 years' duration was associated with an IgG kappa monoclonal gammopathy and recurrent uveitis. The corneal changes were unusually extensive and distributed throughout all corneal layers. The deposits consisted of diffuse, small, polymorphic aggregates, which were iridescent in the superficial cornea, mat elsewhere, and associated with a diffuse stromal haze; specular microscopy showed additional features. Both corneas were thickened. The deposits failed to stain histochemically, except patchily with Masson Trichrome. There was extensive immunohistochemical labeling for IgG, kappa, and surprisingly, lambda. Ultrastructurally, pleomorphic deposits were found in every corneal cell; paracrystalline deposits with internal banding were seen only in the basal epithelium. Keratocytes and endothelial cells were damaged and reduced in number. Disease recurred in a corneal graft. Three main types of paraproteinemic keratopathy can be distinguished. The deposits probably represent various metabolic products of the monoclonal protein. This is not necessarily a benign condition; hematologic control may be necessary on purely ophthalmological criteria.

Spatial and temporal sequence of corneal crystal deposition in nephropathic cystinosis

We studied 15 patients with infantile nephropathic cystinosis. We found that anterior corneal cystine crystal deposition began early in life and proceeded posteriorly as the patient aged; deposition advanced more rapidly in the periphery. Ultrastructural analysis of a corneal button obtained from a 20-year-old patient undergoing corneal transplantation confirmed our clinical observations that crystals were deposited throughout the entire central stroma.

Plasmapheresis in paraproteinemia

Indications, results, techniques, laboratory monitoring and complications of therapeutic plasmapheresis in patients with symptomatic paraproteinemia are reviewed. In paraproteinemia associated with severe complications plasma-pheresis has been used successfully as an emergency treatment, as a treatment that reduces temporarily the paraprotein level until reduction of resynthesis is reached by cytotoxic therapy, or as a longterm adjuvant therapy in cases of slowly proliferating plasmacytoma or lymphoma. Plasmapheresis has not been shown to influence the underlying malignant process. Paraprotein-related complications that can be reduced by plasmapheresis are hyperviscosity, hypervolemia, haemorrhagic diathesis, cryoglobulinemic symptoms, rapidly deteriorating renal insufficiency, visual impairment, and neurologic disturbances. Technically, large-pored plasma filters have some advantage as compared to centrifugation techniques. Paraprotein-specific complications of therapeutic plasmapheresis are rare. As an ancillary treatment, therapeutic plasmapheresis has expanded the therapeutic tools in the management of paraproteinemia.

Corneal crystalline deposits in multiple myeloma. A case report

A 70-year-old man with a seronegative rheumatoid arthritis showed some peculiar lamellar crystalline deposits mainly at the Descement/endothelial level in both eyes. Serum protein analysis revealed a monoclonal gammopathy with increased amounts of IgG and K-light chains along with traces of the latter in the urine. Corneal biopsy was not available, but electron microscopy of the conjunctival specimen demonstrated crystalline deposits within the endoplasmic reticulum of plasma cells lying within the connective tissue. This material is supposed to be of protein nature. It seems reasonable that the conjunctival deposits are identical to those seen in the cornea by slit-lamp examination, and it is also suggested that they represents paraprotein aggregates. After treatment with melphalan (Alkeran) and prednisone systemically, the corneal deposits decreased over a period of 9 months with corresponding improvement of the visual acuity.

Ocular copper deposition associated with pulmonary carcinoma, IgG monoclonal gammopathy and hypercupremia. A clinicopathologic correlation

Hypercupremia with central deposition of copper in Descemet's membrane and lens capsule has been reported previously in lymphoproliferative disorders in two cases. A 60-year-old white man presented with visual acuity loss and was found to have an iridescent brown corneal and lenticular discoloration. Laboratory investigation revealed hypercupremia secondary to a poorly differentiated adenocarcinoma of the lung. Presence of copper in the eye was confirmed by specific atomic absorption spectra and histochemical stains of ocular tissue. This appears to be the first report of a carcinoma with associated hypercupremia presenting initially with ocular copper deposition.