BILATERAL AMYLOIDOSIS OF THREE EYELIDS. A CASE REPORT

AIM

To present rare form of lids amyloidosis, in the context with literature and remind a Czech professor Vrabec, F., MD, an important pan-European ocular histologist.

CASE REPORT

37 years aged man was examined for eyelids mass on the department of ophthalmology of the Teaching Hospital Kralovske Vinohrady, Prague, Czech Republic in June 2018. The finding looked like chronic chalazion on the right side and chronic hordeolum on the left side. No acute phase was noted within last several months by the patient. Yellowish to lightly brown friable, partially transparent mass was obtained by excision. Amyloidosis of the AL type was revealed histologically, and diagnosis was followed by extended excision and plastic surgical reconstruction of the lower eyelids on both sides. No systemic disease underlying the amyloidosis was disclosed by following through diagnostic work-up of the patient.

RESULTS

Amyloidosis was illustrated initially by Congo red staining with characteristic dichroism in the polarized light, then it was analysed immunohistochemically, with positivity for kappa light chains. Systemic amyloidosis was excluded, as well as monoclonal gamapathy. Only slightly increased number of plasmacytes (up to 10 %) was revealed in the bone marrow biopsy. The surgical solution was optimal for the patient, and he was without any recurrence and problems of lower eyelids three years.

CONCLUSION

Described case of bilateral eyelids amyloidosis without underlying systemic disease belongs to rare cases and also illustrates necessity of complex interdisciplinary cooperation in the diagnostic process.

Ocular Involvement in Hereditary Amyloidosis

The term amyloidosis describes a group of rare diseases caused by protein conformation abnormalities resulting in extracellular deposition and accumulation of insoluble fibrillar aggregates. So far, 36 amyloid precursor proteins have been identified, and each one is responsible for a specific disease entity. Transthyretin amyloidosis (ATTRv) is one of the most common forms of systemic and ocular amyloidosis, due to the deposition of transthyretin (TTR), which is a transport protein mainly synthesized in the liver but also in the retinal pigment epithelial cells. ATTRv amyloidosis may be misdiagnosed with several other conditions, resulting in a significant diagnostic delay. Gelsolin and keratoepithelin are other proteins that, when mutated, are responsible for a systemic amyloid disease with significant ocular manifestations that not infrequently appear before systemic involvement. The main signs of ocular amyloid deposition are in the cornea, irido-corneal angle and vitreous, causing complications related to vasculopathy and neuropathy at the local level. This review aims at describing the main biochemical, histopathological and clinical features of systemic amyloidosis associated with eye involvement, with particular emphasis on the inherited forms. We discuss currently available treatments, focusing on ocular involvement and specific ophthalmologic management and highlighting the importance of a prompt treatment for the potential sight-threatening complications derived from amyloid deposition in ocular tissues.

Marked biochemical difference in amyloid proportion between intra- and extraocular tissues in a liver-transplanted patient with hereditary ATTR amyloidosis

In order to elucidate the pathomechanism of ocular amyloid formation in a liver-transplanted patient with hereditary ATTR amyloidosis, we investigated detailed biochemical features of ocular amyloid. The patient was a 49-year-old woman with V30M transthyretin (TTR) variant (p.TTRV50M), who underwent ophthalmectomy due to corneal rupture 10 years after liver transplantation (LT). The amyloid was selectively isolated from several portions in intra- and extraocular tissues using a laser microdissection (LMD) system and analyzed by liquid chromatography-tandem mass spectrometry to determine the composition percentage of wild-type and variant TTR in the isolated amyloid. Biochemical analysis revealed that the amyloid consisted mainly of variant TTR in intraocular tissues with a percentage > 80%. On the contrary in the extraocular muscles, wild-type TTR was the main component of the amyloid with a percentage of ∼70%. Our data indicate that intraocular amyloid formation strongly depends on locally synthesized variant TTR and the contribution of wild-type TTR to amyloid formation is quite limited.

Primary localized conjunctival amyloidosis: A case report with a ten-year follow-up period

A 57-year-old woman consulted our department about a plaque that had been present in her left eye for one year. Ophthalmological examination revealed a solid mass in the left conjunctival semilunar fold. An excitional biopsy was peformed, revealing an amyloid deposition. The patient was referred to the Internal Medicine Department for systemic study. All studies were negative for systemic amyloidosis. Throughout ten years of follow-up study, the patient has shown neither conjunctival recurrence nor any evidence of systemic amylodosis. Despite the fact that several authors have described ocular amyloidosis as an ophthalmologic manifestation of systemic amyloidosis, conjunctival location of amyloidosis is a very rare condition. Amyloid characterization in ocular structures should not be considered a final diagnosis since involvement of systemic underlying diseases must be ruled out. We report a case of localized conjunctival amyloidosis with a ten-year follow-up period that excluded ocular or systemic diseases.