Conjunctival Amyloidosis in Association with Systemic Amyloid Disease

Ocular amyloidosis, with special reference to the hereditary forms with vitreous involvement

The complex of diseases referred to as amyloidosis is characterized by the deposition of amyloid substance in various tissues. The amyloid protein differs in the various forms of amyloidosis. This variation is the basis of the differences in affected tissues and subsequent clinical dissimilarities. Vitreous involvement in amyloidosis seems to be especially linked to some of the hereditary neuropathies associated with the amyloid protein transthyretin. Characterization of the amyloid proteins during recent decades has allowed a chemical and immunologic classification of amyloid fibrils. This paper presents the basis for classification of amyloidosis, reviews the literature on ocular amyloidosis, with special reference to vitreous involvement, and summarizes clinical findings and frequency of vitreous amyloid involvement in Swedish patients with familial amyloidotic polyneuropathy.

Primary systemic amyloidosis: a unique case complaining of diffuse eyelid swelling and conjunctival involvement

A 52-year-old Japanese woman with the chief complaint of marked swelling of her upper eyelids and a mass over the bulbar conjunctiva is reported. She previously noticed frequent purpura after minimal trauma, which was resolved shortly after taking some ascorbic acid. Laboratory data showed Ig-G kappa type M-protein in the serum and kappa type Bence-Jones protein in the urine by immunoelectrophoresis. Systemic examination showed mild hepatosplenomegaly, 1st degree of AV block, and a mild increase in plasma cells in the bone marrow biopsy. Histologically, the whole dermis of the eyelid skin and conjunctiva was replaced by a large quantity of amorphous, eosinophilic substances, which were diffusely positive with Direct Fast Scarlet 4BS. Immunohistochemical staining was positive for anti-amyloid P component antibody. Typical amyloid fibrils were proved by electron microscopy. She was finally diagnosed as primary systemic amyloidosis with diffuse swollen eyelids and conjunctival mass, symptoms which in primary systemic amyloidosis are very rare.

Localized conjunctival amyloidosis associated with extranodal lymphoma

A 62-year-old man was found to have a large asymptomatic amyloid nodule of the conjunctiva. Within the next year, a diffuse mixed small and large cell lymphoma of his scapula developed with amyloid in its stroma. No abnormal serum or urine protein was found. Subsequently, rib and paraspinal masses appeared. After irradiation and chemotherapy, the patient died of bronchopneumonia, 3 years after onset. By immunostaining, the amyloid of both conjunctiva and scapular tumor was of polyclonal immunoglobulin (AL) type, most prominently IgG and lambda chains, with lesser staining for IgA and kappa chains. The tumor cells showed a similar pattern. To our knowledge, this is the first report of systemic lymphoma and localized conjunctival amyloidosis without a serum paraprotein, and the first such association with a lymphoma of this cell type. Immunotyping of conjunctival amyloidosis should be performed to guide the workup for possible systemic disease.

Amyloid tumor of the orbit

A patient with an amyloid tumor of the orbit was studied by computed tomographic scanning. The tumor density was 10 delta units unenhanced and 72 units enhanced.

Localized conjunctival amyloidosis

We treated a patient with localized amyloidosis of the bulbar conjunctiva, which strongly resembled a neoplastic growth. Although the patient suffered from a long-standing, debilitating rheumatoid arthritis, suggesting the possibility of a secondary systemic amyloidosis caused by the chronic effusive process, no specific clinical evidence of systemic amyloidosis was noted. The ocular lesion was, therefore, classified as a primary localized amyloidosis. However, the simple recognition of amyloid in the ocular adnexa should not be considered a complete diagnosis. For such cases in which a prominent underlying systemic disease is present, a thorough medical evaluation and future follow-up should be ensured to rule out the possibility that this represents the initial manifestation of a potentially life-threatening secondary systemic amyloidosis caused by rheumatoid arthritis.

Intraorbital amyloid

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Amyloidosis of the cornea

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Amyloid tumours of the orbit

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