Serous macular detachment in Waldenström macroglobulinemia: a report of four cases

Central serous chorioretinopathy: An evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a relatively common disease that causes vision loss due to macular subretinal fluid leakage and it is often associated with reduced vision-related quality of life. In CSC, the leakage of subretinal fluid through defects in the retinal pigment epithelial layer's outer blood-retina barrier appears to occur secondary to choroidal abnormalities and dysfunction. The treatment of CSC is currently the subject of controversy, although recent data obtained from several large randomized controlled trials provide a wealth of new information that can be used to establish a treatment algorithm. Here, we provide a comprehensive overview of our current understanding regarding the pathogenesis of CSC, current therapeutic strategies, and an evidence-based treatment guideline for CSC. In acute CSC, treatment can often be deferred for up to 3-4 months after diagnosis; however, early treatment with either half-dose or half-fluence photodynamic therapy (PDT) with the photosensitive dye verteporfin may be beneficial in selected cases. In chronic CSC, half-dose or half-fluence PDT, which targets the abnormal choroid, should be considered the preferred treatment. If PDT is unavailable, chronic CSC with focal, non-central leakage on angiography may be treated using conventional laser photocoagulation. CSC with concurrent macular neovascularization should be treated with half-dose/half-fluence PDT and/or intravitreal injections of an anti-vascular endothelial growth factor compound. Given the current shortage of verteporfin and the paucity of evidence supporting the efficacy of other treatment options, future studies-ideally, well-designed randomized controlled trials-are needed in order to evaluate new treatment options for CSC.

Hyperviscosity Syndrome Induced Bilateral Visual and Auditory Impairment in Therapy Resistant Waldenström Macroglobulinemia with MYD88 and CXCR4 Mutations

Hyperviscosity syndrome (HVS) is an emergent complication of Waldenström macroglobulinemia (WM) characterized by visual, neurologic, and rarely auditory impairment. We report a 69-year-old female with MYD88 and CXCR4-mutant WM who developed HVS resulting in bilateral blindness and deafness associated with neurologic manifestations including confusion, severe generalized weakness, and imbalance. Ophthalmologic evaluation revealed bilateral central retinal vein occlusion (CRVO), diffuse retinal hemorrhages, macular edema, and serous macular detachments (SMD). Magnetic resonance imaging of the brain showed bleeding in the inner ears. Management was challenging as her WM was resistant to systemic therapies including bendamustine + rituximab (BR) and rituximab + bortezomib + dexamethasone (RVD). Bruton's tyrosine kinase inhibitors could not be used initially due to ongoing lower gastrointestinal bleeding. She required five total sessions of plasma exchange and was finally initiated on zanubrutinib, achieving a partial response. She also received intravitreal bevacizumab with rapid resolution of the retinal hemorrhages but with little improvement of the SMD. She had partial restoration of her hearing in the right ear and only slight improvement in her bilateral visual deficits. The management of HVS in frail, elderly patients with therapy-resistant WM can be challenging. In these cases, plasma exchange is required until an effective systemic therapy can be safely instituted. Genomic profiling is important in the management of WM as it can predict treatment resistance and guide therapeutic decisions.

Multimodal Imaging Characteristics and Risk Factors Analysis of Waldenström Macroglobulinemia Retinopathy

PURPOSE

To summarize the multimodal imaging features and analyze the risk factors of Waldenström macroglobulinemia retinopathy (WMR).

DESIGN

Retrospective, cross-sectional study.

METHODS

Patients diagnosed with WM and underwent ophthalmic examination in Peking Union Medical College Hospital in the last decade were included. Multimodal imaging characteristics of WMR were summarized. Univariate and multivariate logistic regression analysis of WMR and potential systemic and ocular factors was performed.

RESULTS

A total of 50 patients with WM were included in this study, and 28 patients had WMR in at least 1 eye. WMR was found to have worse LogMAR visual acuity (0.52 ± 0.54 vs 0.21 ± 0.18, P = .009) and was characterized by tortuous retinal vessels, extensive retinal hemorrhage, distinctive shape of macular edema, and so on. In univariate analysis, the presence of WMR was significantly associated with the mean visual acuity (LogMAR), serum red blood cell counts, serum platelet counts, hemoglobin level, serum M protein, serum IgM level, and lactate dehydrogenase (with P < .05). In multivariate analysis, WMR was significantly correlated with M protein (adjusted odds ratio = 1.127, 95% CI: 1.052-1.209, P= .001) and serum IgM (adjusted odds ratio = 1.059, 95% CI: 1.023-1.095, P = .001) with the predicted areas under the curve of 0.859 and 0.820, respectively. The optimal cutoff values were 26.2 g/L for M protein and 51.0 g/L for IgM, which accounts for a sensitivity of 95.4% and 95.4% and specificity of 64.3% and 60.7%, respectively.

CONCLUSIONS

WMR has specific characteristics in ophthalmic examinations. Serum IgM levels and M protein are good predictors of WMR, which could attach important value of fundus examinations for patients with WM.

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.

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.

Cystoid macular oedema without leakage in fluorescein angiography: a literature review

Cystoid macular oedema (CMO), which is defined as a macular thickening and cystic changes due to accumulation of fluid, could be asymptomatic and only diagnosed using paraclinical techniques. Fluorescein angiography (FA) and optical coherence tomography (OCT) are useful in detecting CMO in clinical practice. Non-leaking CMO, also known as angiographically silent CMO, is referred to as cases of CMO without leakage in fluorescein angiography. This type of CMO has been reported in some retinal dystrophies, in cases of maculopathy as a side effect of certain drugs, and also in some systemic disorders. The exact mechanism and treatment options for this type of CMO are still not clear. This literature review aims to discuss different causes of non-leaking CMO, proposed mechanisms, and management options. Three sections including drugs, retinal dystrophies, and systemic disorders are discussed in this review.

Bilateral central retinal vein occlusion as an initial presentation of Waldenström macroglobulinemia: a case report

BACKGROUND

Waldenström macroglobulinemia is a rare hematological malignancy and is the most common diagnosis in patients with hyperviscosity syndrome. Bilateral central retinal vein occlusion as an initial presentation of hyperviscosity syndrome in Waldenström macroglobulinemia is rare.

CASE PRESENTATION

A 42-year-old Nepalese male presented with sudden-onset bilateral painless blurring of vision. Fundus examination revealed bilateral, diffusely dilated, tortuous retinal veins and intraretinal deep blot hemorrhages in all four quadrants of the retina in both eyes; features of bilateral central retinal vein occlusion. Serum electrophoresis showed hypoalbuminemia with an immunoglobulin M kappa monoclonal spike. Bone marrow picture and immunohistochemistry analysis were suggestive of lymphoplasmacytic lymphoma. The patient received systemic therapy for Waldenström macroglobulinemia, along with intravitreal bevacizumab.

CONCLUSION

Adequate hydration, plasmapheresis, and a combination of bortezomib, dexamethasone, and rituximab regimen as a systemic therapy may represent an ideal choice for patients with hyperviscosity in Waldenström macroglobulinemia.

Multimodal imaging of bilateral immunogammopathy maculopathy associated to Waldenström's macroglobulinemia

AIM

Our aim is to report a case with bilateral Waldenström's macroglobulinemia (WM) associated maculopathy, assessed with multimodal imaging including swept source optical coherence tomography (SS-OCT) and OCT-Angiography (OCT-A).

METHODS

Observational case report.

CASE PRESENTATION

A 61-year-old diabetic woman with history of treated WM currently in remission, presented with progressive bilateral visual loss. Best-corrected visual acuity was 20/100 in the right eye (RE) and 20/200 in the left eye (LE). Fundus examination showed bilateral microaneurysms and retinal punctuate hemorrhages and a large macular serous detachment in the LE. There was no retinal ischemia on FA nor macular dye leakage. SS-OCT showed a significant schisis-like intraretinal fluid accumulation in the RE and a large prominent macular detachment with significant subretinal fluid accumulation in the LE. Retinal and choriocapillaris vascular densities were normal on OCT-A.

CONCLUSION

Our case illustrated characteristic multimodal imaging findings in WM associated maculopathy such as schisis-like intraretinal fluid accumulation and angiographically silent serous macular detachment. OCT-A could non-invasively analyze macular vascular densities layer-by-layer, without noticing any vascular anomaly.

The Spectrum of Ocular Manifestations in Patients with Waldenström's Macroglobulinemia

PURPOSE

To investigate the ocular manifestations in 91 Waldenström's macroglobulinemia (WM) patients.

METHODS

Retrospective, cross-sectional, observational analysis.

RESULTS

Ocular impairments, detected in 19 patients, included flame-shaped hemorrhages, venous sausaging, papilledema, macular detachments, or central retinal vein occlusion in 16 patients; paraproteinemic keratopathy in 2; and a CANOMAD syndrome in 1. Best-corrected visual acuity was ≥0.5 logMAR units in 11 of 38 eyes. Intraocular pressure was increased in seven eyes. Genetic analysis in seven patients showed a mutation in the MYD88 gene in six patients and a nonsense mutation in the CXCR4 gene in five patients. Plasmapheresis followed by chemotherapy with or without the addition of rituximab resulted in improvement or normalization of the ophthalmological findings in 15 patients.

CONCLUSION

The ocular manifestations of WM are protean and potentially sight threatening. Recent advances in genomic profiling and chemotherapy have remarkably improved the hematological and ophthalmological outcomes of these patients.

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.

SEROUS MACULAR DETACHMENT ASSOCIATED WITH WALDENSTROM MACROGLOBULINEMIA MANAGED WITH IBRUTINIB: A CASE REPORT AND NEW INSIGHTS INTO PATHOGENESIS

PURPOSE

To report a case of serous macular detachment in a patient with Waldenstrom macroglobulinemia treated with ibrutinib.

METHODS

The patient underwent a complete ophthalmic examination and imaging at presentation and at follow-up visits up to 13 months.

RESULTS

At presentation, there were serous macular detachments bilaterally with no dye leakage on fluorescein angiography or vasculature abnormalities on optical coherence tomography angiography. After treatment with ibrutinib, there was near resolution of the patient's retinopathy with an improvement in vision at 13 months' follow-up.

CONCLUSION

Serous macular detachments in Waldenstrom macroglobulinemia-associated retinopathy may be due to the disruption of the retinal pigment epithelium pump mechanism by hyperglobulinemia. The favorable course of this patient, treated with the novel tyrosine kinase inhibitor ibrutinib, suggests this may be the preferred treatment for Waldenstrom macroglobulinemia patients with associated retinopathy.

Serous business: Delineating the broad spectrum of diseases with subretinal fluid in the macula

A wide range of ocular diseases can present with serous subretinal fluid in the macula and therefore clinically mimic central serous chorioretinopathy (CSC). In this manuscript, we categorise the diseases and conditions that are part of the differential diagnosis into 12 main pathogenic subgroups: neovascular diseases, vitelliform lesions, inflammatory diseases, ocular tumours, haematological malignancies, paraneoplastic syndromes, genetic diseases, ocular developmental anomalies, medication-related conditions and toxicity-related diseases, rhegmatogenous retinal detachment and tractional retinal detachment, retinal vascular diseases, and miscellaneous diseases. In addition, we describe 2 new clinical pictures associated with macular subretinal fluid accumulation, namely serous maculopathy with absence of retinal pigment epithelium (SMARPE) and serous maculopathy due to aspecific choroidopathy (SMACH). Differentiating between these various diseases and CSC can be challenging, and obtaining the correct diagnosis can have immediate therapeutic and prognostic consequences. Here, we describe the key differential diagnostic features of each disease within this clinical spectrum, including representative case examples. Moreover, we discuss the pathogenesis of each disease in order to facilitate the differentiation from typical CSC.

Multimodal imaging of two cases of retinal vein occlusion secondary to Waldenstrom macroglobulinemia

PURPOSE

To report multimodal imaging characteristics of two cases of retinal vein occlusion (RVO) secondary to Waldenstrom macroglobulinemia (WM).

CASE REPORT

Case 1: An 82-year-old woman presented with vision loss. She had a history of WM. Best-corrected visual acuity (BCVA) was 20/100 Snellen equivalent in the right eye (OD) and 20/63 in the left eye (OS). Fundoscopy showed bilateral hemorrhages in posterior pole and along superotemporal arcade. Fluorescein angiography illustrated no macular leakage. Optical coherence tomography (OCT) revealed macular edema (ME). Optical coherence tomography angiography (OCTA) demonstrated abnormalities in choriocapillaris. A diagnosis of bilateral branch RVO was made and ME was treated with intravitreal dexamethasone, achieving stability. Case 2: A 65-year-old man presented with venous dilation, tortuosity, and intraretinal hemorrhages. BCVA was 20/20 in both eyes (OU). OCT showed ME and hyperreflective dots in choroid. A diagnosis of bilateral central RVO was made. Laboratory evaluation and bone narrow biopsy confirmed a diagnosis of WM. After that, our patient consulted because of vision loss. BCVA was 20/400 in OU. Fundoscopy and OCT demonstrated a worsening of the intraretinal hemorrhages and the ME. OCTA showed damage of choriocapillaris. Thus, intravitreal dexamethasone and plasmapheresis was advised. Two months after, BCVA was 20/40 in the OD and 20/32 in the OS. Also, fundoscopy and OCT improved.

CONCLUSION

Early treatment of WM is truly important, with the aim of achieving a decrease in IgM levels in order to avoid toxic effect over the RPE that results in refractory ME.

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).

Central serous chorioretinopathy: An update on risk factors, pathophysiology and imaging modalities

Central serous chorioretinopathy (CSC) is a common form of vision loss, typically seen in working-age men. The pathophysiology behind CSC still eludes us, however significant advances have been made in understanding this disease over the last decade using information from genetic and cell-based studies and imaging modalities. This review aims to give an overview of the current pathophysiology hypotheses surrounding CSC in addition to future directions in cellular work from human induced pluripotent stem cell derived choroidal endothelial cells from CSC patients. Furthermore, this review will provide the reader with an update on the clinical aspects of CSC including risk factors, diagnostic challenges and findings from multimodal imaging.

Central serous chorioretinopathy: Towards an evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a common cause of central vision loss, primarily affecting men 20-60 years of age. To date, no consensus has been reached regarding the classification of CSC, and a wide variety of interventions have been proposed, reflecting the controversy associated with treating this disease. The recent publication of appropriately powered randomised controlled trials such as the PLACE trial, as well as large retrospective, non-randomised treatment studies regarding the treatment of CSC suggest the feasibility of a more evidence-based approach when considering treatment options. The aim of this review is to provide a comprehensive overview of the current rationale and evidence with respect to the variety of interventions available for treating CSC, including pharmacology, laser treatment, and photodynamic therapy. In addition, we describe the complexity of CSC, the challenges associated with treating CSC, and currently ongoing studies. Many treatment strategies such as photodynamic therapy using verteporfin, oral mineralocorticoid antagonists, and micropulse laser treatment have been reported as being effective. Currently, however, the available evidence suggests that half-dose (or half-fluence) photodynamic therapy should be the treatment of choice in chronic CSC, whereas observation may be the preferred approach in acute CSC. Nevertheless, exceptions can be considered based upon patient-specific characteristics.

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.

MULTIMODALITY OCULAR IMAGING IN A CASE REPORT OF HYPERVISCOSITY SYNDROME ASSOCIATED WITH LYMPHOPLASMACYTIC LEUKEMIA: THE IMAGES TELL THE STORY

PURPOSE

To report the clinical course of a patient with ocular manifestations of hyperviscosity syndrome associated with Waldenström macroglobulinemia, and for the first time, video imaging of mobile emboli in the conjunctival and retinal vasculature.

METHODS AND PATIENT

A 60-year-old woman with newly diagnosed Waldenström macroglobulinemia, with no visual complaints was evaluated by the Ophthalmology service for a baseline ocular examination.

RESULTS

At presentation, ocular examination revealed a visual acuity of 20/25 in each eye. Slit lamp examination showed mobile white emboli throughout the conjunctival vasculature of both eyes, which was captured on video. Dilated fundus examination revealed peripheral vascular occlusion along with extensive collateral formation in both eyes and as dilation of vessels at the posterior pole of the left eye. Mobile arterial and venous emboli were also observed in the retinal vasculature, which were captured with slit-lamp color and infrared reflectance video imaging.

CONCLUSION

Hyperviscosity syndrome is a rare circulation sequelae that occurs when blood is thickened secondary to an increase in immunoglobulins or a hyperproliferation of blood components as in bone marrow dyscrasias. The increase in viscosity is plainly observable in the retinal circulation, and this syndrome is often diagnosed based on visual symptoms and fundus examination. We report a patient with Waldenström macroglobulinemia who presented with multiple ocular manifestations of hyperviscosity syndrome despite the absence of visual complaints. Ophthalmologists should be aware that regardless of the lack of any subjective visual changes, ocular findings of hyperviscosity syndrome should prompt quick referral to a Hematology Oncologist for evaluation of other end-organ damage. We also for the first time, provide video documentation of mobile emboli in the conjunctival and retinal vasculature.

Vasoproliferative retinopathy secondary to Waldenström's disease

A 66 year-old patient, monitored for diabetic retinopathy refractory to multiple treatment methods despite a good metabolic control, referred to progressive weight loss. For this reason, a systemic study was performed, detecting anaemia, elevation of the erythrocyte sedimentation rate, and hyperproteinaemia due to elevated serum levels of monoclonal IgM. Subsequently, by performing a bone marrow biopsy and genetic study, the diagnosis of Waldenström macroglobulinaemia was made. Waldenström's macroglobulinaemia is a low frequency lymphoproliferative disease, for which the main manifestation is a hyperviscosity syndrome that can produce ophthalmological signs detectable by funduscopy and imaging tests. A multimodal study is useful in the diagnosis and monitoring of retinal involvement. The incorporation of angiography by optical coherence tomography allows a more precise study of the microvascular disorders that may occur at the posterior pole level.

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.

Localized retinal degeneration secondary to Waldenström's macroglobulinemia

A 52-year-old man, treated for Waldenström's macroglobulinemia (WM), continued to experience decreased vision even after 24 months. He was evaluated using multimodal imaging and electroretinography. The retina did not show any hyperviscosity changes but revealed a yellow lesion at macula with atrophic changes causing a pattern on fluorescein angiography similar to a leopard's skin. Optical coherence tomographic imaging revealed uniformly reflective material deposited in the outer retina with degeneration of outer retinal layers. Full-field electroretinography was normal, but multifocal electroretinography revealed reduced foveal responses. This case highlights the degenerative effects of long-standing immunogammopathy maculopathy in WM.

ACQUIRED VITELLIFORM DETACHMENT IN MULTIPLE MYELOMA

PURPOSE

To report a case of subfoveal acquired vitelliform detachment in a patient with multiple myeloma.

METHODS

Case report.

RESULTS

A 65-year-old man was referred for treatment of a serous macular detachment considered to be caused from chronic central serous chorioretinopathy or adult pseudovitelliform macular dystrophy. His medical history revealed an untreated multiple myeloma. Systemic chemotherapy was undertaken and resulted in a rapid resolution of the detachment.

CONCLUSION

Multiple myeloma may be considered as a possible cause of vitelliform macular detachment.

Seeing through thick and through thin: Retinal manifestations of thrombophilic and hyperviscosity syndromes

The presence of retinal vasculopathy in the absence of typical predisposing factors should suggest a possible underlying hematologic abnormality. In such cases, a systemic investigation may reveal a potentially fatal hypercoagulability or hyperviscosity syndrome. Retinal vein occlusion is the most commonly encountered ophthalmic finding in such syndromes; however, abnormalities of the arterial system, the choroid, and the macula are also possible. Visual symptoms may be the only manifestation of the underlying process, making timely diagnosis by the ophthalmologist critical for both treatment and thrombotic prophylaxis. Moreover, as newer ophthalmic diagnostic technologies arise, there is an increasingly important role for eye physicians in the management of such syndromes.

Bevacizumab therapy and multimodal ultrawide-field imaging in immunogammopathy maculopathy secondary to Waldenström's macroglobulinemia

Waldenström's macroglobulinemia (WM) is associated with retinal findings of hyperviscosity, such as venous dilation, and findings of immunogammopathy maculopathy, such as serous macular detachment. This report describes a case of bilateral serous macular detachment with intraretinal schisis-like fluid in a patient with WM. Enhanced depth imaging optical coherence tomography revealed a thickened choroid with hyperreflective accumulations in the retinal pigment epithelium layer. Ultrawide-field fundus autofluorescence demonstrated a central area of hyperautofluorescence corresponding to the area of serous macular detachment. Ultrawide-field fluorescein angiography was characteristically silent. Intravitreal bevacizumab therapy resulted in significant reduction in intraretinal fluid but minimal change in subretinal fluid. Long-term follow-up demonstrated alterations in retinal architecture and improved serous detachments.

Bevacizumab in macular serous detachments associated with Waldenstrom's macroglobulinemia

Waldenström's macroglobulinemia (WM) is a lymphoproliferative B-cell disorder characterized by monoclonal proliferation of immunoglobulin M. WM can be associated with impressive hyperviscosity retinopathy and a unique tendency to develop serous macular detachments. These have been described as immunogammopathy maculopathy and portend a poor visual prognosis, often persisting despite multiple plasmapheresis treatments. In this case report, the authors demonstrate the accelerated resolution of hyperviscosity retinopathy and associated macular detachments in a patient with WM with marked visual improvement. This case report serves to raise awareness of the potential role of anti-vascular endothelial growth factor modulation in the treatment of patients with hyperviscosity retinopathy associated with WM.

Serous macular detachment, yellow macular deposits, and prominent middle limiting membrane in multiple myeloma

Bone marrow-derived multiple myeloma is a type of plasma cell tumor that may be associated with ocular complications. A 52-year-old male patient was admitted to our eye clinic with the complaint of sudden visual loss and a visual acuity of 20/50 in the right eye and 20/800 in the left eye. Fundus examination revealed common flame-shaped hemorrhages, venous dilatation and tortuosity, Roth spots, serous macular detachment, and yellow macular deposits in both eyes. Evaluation with fundus fluorescein angiography, fundus autofluorescence, and spectral-domain optical coherence tomography resulted in suspicion of hyperviscosity retinopathy and referral to the hematology clinic. After hematology consultation confirmed a diagnosis of multiple myeloma, chemotherapy and plasmapheresis were initiated. Four months after presentation, best-corrected visual acuity was 20/20 in both eyes and improvement in hyperviscosity retinopathy, serous macular detachment, and yellow macular deposits was observed.

Bilateral macular detachments, venous stasis retinopathy, and retinal hemorrhages as initial presentation of multiple myeloma: a case report

PURPOSE

To present the case of a patient with bilateral macular detachments, venous stasis retinopathy, and retinal hemorrhages as the initial manifestation of multiple myeloma.

METHODS

Case report.

RESULTS

A 59-year-old woman presented with complaints of photopsias and decreased vision and was found to have bilateral macular detachments, venous stasis retinopathy, and retinal hemorrhages. Fluorescein angiography revealed an angiographically silent fundus in both eyes, indicating no fluorescein leakage was found in the macula. Workup revealed multiple myeloma as the cause of the retinal findings.

CONCLUSION

Macular detachment or subretinal fluid, retinal venous dilation or congestion, and retinal hemorrhages may be presenting signs of multiple myeloma.

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.

Immunogammopathies and acquired vitelliform detachments: a report of four cases

PURPOSE

To describe the nature and evolution of acquired macular detachments in patients with immunogammopathies and to propose a mechanism for their development.

DESIGN

Retrospective observational case series.

METHODS

Three patients with multiple myeloma and 1 with light chain deposition disease were diagnosed with vitelliform macular detachments based on clinical examination, fundus autofluorescence, fluorescein angiography, and optical coherence tomography. These patients were followed over time and their clinical examinations and imaging studies were compared and contrasted.

RESULTS

Three patients (5 eyes) with multiple myeloma and 1 patient (2 eyes) with light chain deposition disease presented with acquired macular yellowish subretinal deposits on funduscopic examination that corresponded to hyperautofluorescent lesions on fundus autofluorescence imaging and subretinal hyperreflective material on spectral-domain optical coherence tomography. One patient (2 eyes) had diffuse serous retinal detachments involving not only the macular region but also the midperiphery of the retina. These acquired macular vitelliform detachments were not associated with signs of hyperviscosity retinopathy in 5 eyes and resolved after successful treatment of the multiple myeloma in 6 eyes.

CONCLUSION

Patients with an immunogammopathy such as multiple myeloma or light chain deposition disease may develop serous elevations of the macula that we classify as acquired vitelliform detachments using multimodal imaging. Appropriate evaluation including serum protein electrophoresis and hematology consultation should be considered in the management of patients with acquired vitelliform detachments of uncertain etiology.