Bilateral central retinal vein occlusion in multiple myeloma

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.

Efficacy of plasmapheresis as treatment for bilateral hyperviscosity syndrome related retinopathy in multiple myeloma

PURPOSE

To report a case of good clinical response to plasmapheresis as therapy for a bilateral hyperviscosity syndrome related retinopathy in a young patient with undiagnosed multiple myeloma (MM).

METHODS

Case report.

RESULTS

A 48-year-old caucasian man, previously diagnosed with monoclonal gammopathy of undetermined significance (MGUS), presented for medical attention for back ache and vision decrease, worst in the left eye. Ophthalmological examination revealed presence of bilateral CRVO-like retinopathy which raised the hypothesis of hyperviscosity syndrome (HVS). After confirmation of MM diagnosis, plasmapheresis were promptly begun. The right eye regained a good visual acuity and an anatomical restoration already notable 5 days from the first plasmapheresis.

CONCLUSIONS

Fundoscopy lead to diagnosis of HVS, it is therefore advisable in all patients with MM in order to perform plasmapheresis as soon as possible if necessary. In case of atypical CRVO, haematological and inflammatory causes, should be always ruled out.

Hyperviscosity retinopathy as the initial presentation of aggressive multiple myeloma

Multiple myeloma (MM) is a hematologic malignancy resulting from the uncontrolled proliferation of neoplastic plasma cells and the excessive production of monoclonal immunoglobulins, both of which may lead to hyperviscosity retinopathy. Here, we present a 56-year-old male who had progressive painless loss of vision for 1 month. Ophthalmic examination revealed hyperviscosity retinopathy with bilateral central retinal vein occlusion-like appearance. Hematologic assessment revealed immunoglobulin A MM. Although the patient was treated with chemotherapy and autologous stem cell transplantation soon after referral, he did not survive due to the aggressive course of the disease. We highlight the importance of the ophthalmic presentation of MM. Early recognition and referral to an oncologist can lead to timely diagnosis and appropriate management.

Increased risk of cancer in patients with retinal vein occlusion: a 12-year nationwide cohort study

Aims

To investigate the association between incident retinal vein occlusion (RVO) and the subsequent development of cancer.

Methods

In this nationwide population-based retrospective study using 2002–2013 National Health Insurance Service database which covers the entire South Korean population, 186 701 incident RVO patients and their 1:1 propensity-score matched controls were included. We defined the fixed cohort from January 1st, 2004 to December 31st, 2013; the cohort included patients who suffered incident RVO after entering the cohort and their matched controls, and excluded patients having any cancer history before entering the cohort. The association of RVO and cancer was assessed by time-varying covariate Cox regression models; Model 1 included RVO as a time-varying covariate, Model 2 included Model 1 plus demographic information and Model 3 included Model 2 and comorbidities.

Results

RVO was associated with an increased risk of subsequent cancer (HR=1.29; 95% CI, 1.26–1.31 in Model 1), which was consistent in Models 2 and 3. The incidence rate of overall cancer during the study period was 25.55 (95% CI, 25.19–25.91) per 1000 person-years in the RVO group and 18.62 (95% CI, 18.46–18.79) per 1000 person-years in the control group. In the subgroup analysis, haematological malignancies showed the highest association with RVO (HR=1.65; 95% CI, 1.49–1.83).

Conclusion

Patients with RVO have an increased risk of subsequent cancer development even after adjusting for demographic factors and comorbidities. Further study is warranted to elucidate these associations to provide proper recommendations for RVO patients regarding the cancer screening.

Rare Presentation of Bilateral Central Retinal Vein Occlusion and Leukemic Retinopathy in a Young Adult Diagnosed with T-cell Acute Lymphoblastic Leukemia

Simultaneous bilateral central retinal vein occlusion (CRVO) is a rare presentation that warrants consideration of an underlying hyperviscosity state. Increased serum viscosity can lead to the hematologic emergency of leukostasis with resultant vascular obstruction and hypoxic tissue damage. The following case demonstrates the first case of bilateral CRVO in a young adult secondary to acute lymphoblastic leukemia (ALL). A 23-year-old female presented to the emergency department (ED) with two days of worsening bilateral blurry vision and bitemporal headache. Her ocular exam was significant for bilateral intraretinal hemorrhages consistent with CRVO with chest radiograph demonstrating widened mediastinum with perihilar lymphadenopathy and serologic testing revealing ALL with blast crisis. The patient was subsequently admitted to the oncology service for induction chemotherapy. Patients with new headache and bilateral vision changes should prompt a thorough neurological and ophthalmologic exam to assess for underlying systemic pathologies. Concurrent bilateral CRVO is a rare but specific finding for systemic hyperviscosity syndrome, blood dyscrasia, polycythemia, or other serious illness. Early recognition and treatment of the underlying condition can prevent further vision loss and overall morbidity and mortality.

Dexamethasone implant for immunogammopathy maculopathy associated with IgA multiple myeloma

Background:

We describe a case where hyperviscosity retinopathy and immunogammopathy maculopathy were the presenting features of IgA multiple myeloma and report the response of maculopathy to intravitreal injection of dexamethasone implants.

Case presentation:

A 56-year-old man presented at the Department of Ophthalmology with the chief complain of reduced vision for the past 10 days in both eyes. Ophthalmic examination revealed central retinal vein occlusion resembling signs with severe macular edema in both eyes with prominent serous macular detachment. After comprehensive evaluation, an IgA type kappa multiple myeloma was diagnosed complicated with hyperviscosity-associated retinopathy and immunogammopathy maculopathy. Patient was treated with multiple sessions of plasmapheresis, systemic chemotherapy, and finally intravitreal implants of dexamethasone with complete restoration of macular edema and serous macular detachment in both eyes. The visual function and the hyperviscosity-associated retinopathy were partially restored.

Conclusion:

Ocular manifestation might be the only presenting sign of a life-threatening disease such as IgA multiple myeloma. A high level of suspicion is required to diagnose and treat such cases promptly and effectively.

Concomitant multiple myeloma spectrum diagnosis in a central retinal vein occlusion: a case report and review

Multiple myeloma is a neoplastic plasma-cell disorder resulting from malignant plasma cells in the bone marrow. It can cause a hyperviscosity syndrome secondary to the paraproteinaemia associated with the disease. The increased hyperviscosity can lead to retinal vein occlusions and other ocular problems that may challenge clinicians. In patients with multiple myeloma and hypertension and/or diabetes mellitus, retinal changes appear similar and changes due to one disease or the other may be difficult to determine. A 48-year-old white female presented to the clinic with a complaint of blurry vision in her left eye. A full comprehensive ocular examination revealed a central retinal vein occlusion presumably from the patient's history of hypertension, diabetes mellitus and hypercholesterolaemia. Further bloodwork revealed monoclonal protein in the patient's serum and an increased percentage of plasma cells in the bone marrow. She was diagnosed with monoclonal gammopathy of undetermined significance, part of the multiple myeloma disease spectrum. She was referred to a retinal specialist for initiation of intravitreal injections of anti-vascular endothelial growth factor. Multiple myeloma has been implicated in younger patients as an underlying cause of retinal vein occlusions. Multiple myeloma should be considered as a differential diagnosis in young patients with retinal vein occlusions, even if other risk factors for venous occlusion like hypertension, diabetes mellitus and hypercholesterolaemia are present. Timely referral to the patient's primary care physician and haematologist is important for appropriate treatment and control of underlying systemic conditions.

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.

Bilateral BRVO in a patient with recurrent prostate cancer

Bilateral cases of branch retinal vein occlusions (BRVO) are infrequent and often related to systemic disease. A 72-year-old man with biochemical recurrence of prostate cancer was referred for decreased vision in his left eye. Fundus examination and fluorescein angiography disclosed bilateral BRVO with patches of peripheral non-perfusion and macular oedema in the left eye. A systemic work up revealed elevated fibrinogen and reduced free protein S antigen, consistent with an underlying hypercoagulable state. Cancer is a well-known cause of hypercoagulability. We report the first case of bilateral BRVO related to biochemical recurrence of prostate cancer and a proven coagulation derangement.

An otherwise healthy young man presents with bilateral CRVO as the first sign of hyperviscosity syndrome in the setting of new multiple myeloma

PURPOSE

To report a case of bilateral central retinal vein occlusion as the presenting feature of new onset multiple myeloma in an otherwise healthy man.

METHODS

A 44-year-old man presented with painless visual changes in his left eye. Ophthalmic examination revealed what appeared to be bilateral central retinal vein occlusion and hematologic assessment resulted in the diagnosis of immunoglobulin G multiple myeloma.

RESULTS

Initial management was plasma exchange followed by a chemotherapy regimen of cyclophosphamide, bortezomib, and dexamethasone, and subsequent plans for bone marrow transplant.

CONCLUSION

Hyperviscosity syndrome seems similar to central retinal vein occlusion and may be associated with systemic conditions such as diabetes and atherosclerosis; however, alternative etiologies should be considered in young otherwise healthy individuals. This case underscores the need for diligent and thorough investigations for less common systemic conditions associated with retinal vein occlusions by primary care ophthalmologists.