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Kim C, Simon B, Vaidya N, Kirk S, Estes K, Ghadiali L, Kontosis A, Yoo D. Contrasting presentations of the same disease: A comparison of two cases of amyloidosis presenting with eyelid involvement. Am J Ophthalmol Case Rep 2022; 28:101714. [PMID: 36217437 PMCID: PMC9547226 DOI: 10.1016/j.ajoc.2022.101714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 07/26/2022] [Accepted: 09/26/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose Localized amyloidosis can affect numerous tissues throughout the body and can also affect a variety of peri-ocular tissues including the conjunctiva, extra-ocular muscles, peri-orbital soft tissue, and lacrimal gland. We report two cases of amyloidosis presenting with eyelid involvement. Observations The first case represented a more subtle presentation of skin thickening with a pre-septal cellulitis, while the second case had a dramatic presentation of edema evolving into tissue dehiscence and spontaneous hemorrhage with ongoing angioedema and systemic coagulopathy. Conclusions and importance The two cases of biopsy-proven orbital/peri-ocular amyloidosis demonstrate the different clinical presentations that may go from the subtle to dramatic, depending on which peri-ocular tissues are affected and to what degree. Standards for treatment of amyloidosis remain conservative initially with surgery or radiation recommended only for refractory cases, but additional therapies are under investigation. Clinicians should have high clinical suspicion for amyloidosis with findings such as skin thickening or significant periorbital edema and should always consider tissue biopsy and further workup for amyloidosis if the findings worsen or do not resolve with treatment of more common conditions such as cellulitis.
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Affiliation(s)
- Christian Kim
- Loyola University Medical Center Department of Ophthalmology, Building 102/Room 2605, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL, 60153, United States
- Corresponding author.
| | - Brian Simon
- Loyola University Medical Center Department of Ophthalmology, Building 102/Room 2605, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL, 60153, United States
| | - Neel Vaidya
- Loyola University Medical Center Department of Ophthalmology, Building 102/Room 2605, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL, 60153, United States
| | - Suzanne Kirk
- Loyola University Medical Center Department of Ophthalmology, Building 102/Room 2605, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL, 60153, United States
| | - Kimberly Estes
- Loyola University Medical Center Department of Ophthalmology, Building 102/Room 2605, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL, 60153, United States
| | - Larissa Ghadiali
- Loyola University Medical Center Department of Ophthalmology, Building 102/Room 2605, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL, 60153, United States
| | - Andreas Kontosis
- Loyola University Medical Center Department of Pathology, Building 2160 S. First Avenue, Maywood, IL, 60153, United States
| | - David Yoo
- Loyola University Medical Center Department of Ophthalmology, Building 102/Room 2605, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL, 60153, United States
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Kono S, Lee PAL, Kakizaki H, Takahashi Y. Amyloidosis in the Palpebral Conjunctiva Mimicking Lymphoproliferative Lesion. Case Rep Ophthalmol 2021; 12:73-76. [PMID: 33613254 PMCID: PMC7879327 DOI: 10.1159/000510392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/22/2020] [Indexed: 11/20/2022] Open
Abstract
A 47-year-old Japanese woman presented with a 1-year history of foreign body sensation in the right eye. Upon examination, a linear soft tissue lesion in the lower conjunctival fornix was noted. The mass resembled a conjunctival lymphoproliferative lesion but was pinkish-yellow rather than salmon pink in color. Histopathology of the biopsy specimens revealed amyloidosis. Systemic workup showed no other lesions. The conjunctival lesion did not recur at 3 months postoperatively. Since conjunctival amyloidosis mimics conjunctival lymphoproliferative lesions, it is important to keep conjunctival amyloidosis as a differential diagnosis in the diagnosis of a pinkish conjunctival lesion.
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Affiliation(s)
- Shinjiro Kono
- Department of Oculoplastic, Orbital and Lacrimal Surgery, Aichi Medical University Hospital, Nagakute, Japan
| | - Patricia Ann L Lee
- Department of Oculoplastic, Orbital and Lacrimal Surgery, Aichi Medical University Hospital, Nagakute, Japan
| | - Hirohiko Kakizaki
- Department of Oculoplastic, Orbital and Lacrimal Surgery, Aichi Medical University Hospital, Nagakute, Japan
| | - Yasuhiro Takahashi
- Department of Oculoplastic, Orbital and Lacrimal Surgery, Aichi Medical University Hospital, Nagakute, Japan
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Abstract
PURPOSE To describe an unusual cicatrizing manifestation of periocular amyloid and the utility of adjuvant antimetabolite therapy. METHODS This is a case report of a 49-year old woman with progressive bilateral upper lid ptosis, who was found to have bilateral inferior forniceal masses with thickening of the conjunctiva. Conjunctival and eyelid biopsies showed evidence of amyloid deposition. Systemic evaluation did not reveal any evidence of systemic amyloidosis. Her blepharoptosis continued to deteriorate, and she underwent bilateral sequential upper lid ptosis correction surgery and debulking procedures. Subsequently, she developed severe and progressive cicatricial conjunctivitis with extensive symblepharon formation in all 4 fornices and restriction of ocular motility, simulating a clinical picture of ocular mucous membrane pemphigoid. RESULTS She was treated surgically by division of symblepharon augmented with application of topical mitomycin C intraoperatively. This has been partially successful in freeing up differential movement between her lid and her eye and consequently improving eye protection and lubrication. CONCLUSIONS Pseudopemphigoid represents a rare manifestation of periocular amyloid. Risks and benefits of surgical procedures in this context need to be carefully weighed to minimize the risk of secondary complications. Topical mitomycin C may be considered as a relatively safe adjunct in managing the cicatricial component of the disease.
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A Rare Case of Amyloidosis of the Eyelid and Conjunctiva. Case Rep Ophthalmol Med 2016; 2016:2915196. [PMID: 27752377 PMCID: PMC5056286 DOI: 10.1155/2016/2915196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/06/2016] [Indexed: 11/17/2022] Open
Abstract
Amyloidosis of the eyelid is uncommon and is typically associated with systemic associations. In contrast, amyloidosis of the conjunctiva is often localised with no other associations. We present a rare case of a 92-year-old gentleman with both cutaneous lid lesions and conjunctival amyloid with no systemic involvement. Biopsy demonstrated the hallmarks of amyloid and treatment has remained conservative. He remains at the department to be monitored for secondary glaucoma.
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Al-Nuaimi D, Bhatt PR, Steeples L, Irion L, Bonshek R, Leatherbarrow B. Amyloidosis of the orbit and adnexae. Orbit 2012; 31:287-298. [PMID: 22946489 DOI: 10.3109/01676830.2012.707740] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
PURPOSE To present a series of patients with orbital and adnexal amyloidosis and illustrate the diversity of disease and the challenges of managing such cases. METHODS Descriptive case series of ten patients with biopsy proven amyloidosis involving the orbit, conjunctiva and eyelids. The presentation, clinical findings and management are discussed for each case. RESULTS All patients had some form of eyelid abnormality or malposition. Presenting complaints included ptosis, epiphora and ocular discomfort. Other clinical findings included conjunctival lesions and proptosis. The majority of patients had localised amyloidosis and one patient had systemic disease. Conservative management included lubrication and the use of bandage contact lenses. Surgical management included debulking, ptosis or other lid surgery. CONCLUSION Amyloidosis can present to an Occuloplastic clinic in a wide variety of ways. Definitive diagnosis is based on the histopathological findings. Management is often challenging. Multi-disciplinary team involvement is critical in view of its systemic associations.
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Affiliation(s)
- Dania Al-Nuaimi
- Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust , Manchester, UK.
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Abdallah AO, Westfall C, Brown H, Muzaffar J, Atrash S, Nair B. Unilateral conjunctival AL kappa amyloidosis with trace evidence of systemic amyloidosis. AMERICAN JOURNAL OF CASE REPORTS 2012; 13:102-5. [PMID: 23569501 PMCID: PMC3615912 DOI: 10.12659/ajcr.883022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Accepted: 05/10/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND Amyloidosis is a systemic disorder that results from the tissue deposition of various proteins with distinctive morphological characteristics. Conjunctival amyloidosis is a rare variant which is generally localized and not associated with systemic involvement. CASE REPORT We present here a case of 47-year-old female patient with right eyelid swelling that progressed over a 12 year period and eventually underwent surgery with pathology showing AL conjunctival amyloidosis. Unlike in most other reported cases of localized amyloidosis, she was noted to have amyloid deposition in the bone marrow and gastrointestinal tract upon extensive evaluation without any evidence of underlying plasma cell dyscrasia. She has been on observation without evidence of systemic progression or recurrence of conjunctival amyloid. CONCLUSIONS Although it initially appeared that our case represented an isolated form of AL (kappa)-type conjunctival amyloidosis, systemic evaluation revealed trace amount of amyloid in the bone marrow and GI tract. It is feasible that upon very close scrutiny patients with seemingly localized AL amyloidosis may have trace amounts of amyloid involving other organs and based on experience from this single patient we believe that it is safe to observe such patients closely rather than pursue systemic therapy.
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Affiliation(s)
- Al-Ola Abdallah
- Myeloma Institute for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR, U.S.A
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Demirci H, Shields CL, Eagle RC, Shields JA. Conjunctival Amyloidosis: Report of Six Cases and Review of the Literature. Surv Ophthalmol 2006; 51:419-33. [PMID: 16818085 DOI: 10.1016/j.survophthal.2006.04.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Conjunctival amyloidosis is an uncommon condition that occasionally is associated with systemic involvement. The clinical presentations of conjunctival amyloidosis are diverse. We present six patients with conjunctival amyloidosis who were referred to us with the suspicion of another conjunctival lesion. The conjunctival lesion was circumscribed in two patients and diffuse in four patients. The lesion color was yellow in one patient and yellow-pink in five patients. The associated features were intrinsic vascularization (six patients), recurrent subconjunctival hemorrhage (four patients) and blepharoptosis that involved the palpebral conjunctiva (two patients). Systemic evaluation revealed primary systemic amyloidosis in one patient and no related systemic abnormalities in five patients. Management consisted of complete excisional biopsy for the two circumscribed lesions and incisional biopsy for the four diffuse lesions. Two patients with diffuse involvement showed progressive involvement of the conjunctiva over 3 years following incisional biopsy and the other four patients remained stable. Additionally, there was no systemic involvement in five patients. In conclusion, conjunctival amyloidosis generally manifests as a yellowish-pink, hemorrhagic mass deep to the epithelium. Most patients show no evidence of systemic amyloidosis.
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Affiliation(s)
- Hakan Demirci
- Oncology Service, Thomas Jefferson University, Philadephia, PA 19107, USA
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Dithmar S, Linke RP, Kolling G, Völcker HE, Helmke B. Ptosis from localized A-λ-amyloid deposits in the levator palpebrae muscle. Ophthalmology 2004; 111:1043-7. [PMID: 15121386 DOI: 10.1016/j.ophtha.2003.09.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2002] [Accepted: 09/11/2003] [Indexed: 10/26/2022] Open
Abstract
PURPOSE To describe a patient with unilateral ptosis caused by localized amyloid deposits of immunoglobulin lambda-light chains (A-lambda-amyloid) in the levator palpebrae muscle. STUDY DESIGN Case report and literature review. PARTICIPANT A 32-year-old otherwise healthy female with right-sided unilateral ptosis. METHODS The patient presented with right-sided unilateral ptosis without other ocular abnormalities. Palpebral fissures measured 5 mm on the right side and 8 mm on the left. Systemic evaluation, including neurologic and neuroradiologic examinations, was normal. RESULTS Several years after initial presentation, conjunctival amyloid deposits appeared. Ptosis surgery with resection of the levator muscle was performed, revealing massive deposits of A-lambda-amyloid in the excised tissue. CONCLUSIONS Our patient had unilateral ptosis due to localized A-lambda-amyloid deposits in the levator muscle. No other amyloid deposits were initially found. Visible conjunctival deposits developed only years later. Ocular amyloidosis with isolated initial involvement of the levator muscle is a rare condition. Localized monoclonal gammopathy may have been the cause of this unique presentation.
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Affiliation(s)
- Stefan Dithmar
- Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany.
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Abstract
PURPOSE To report a case of conjunctival granuloma formation in response to lodgment of an insect wing. METHOD Case report and review of the literature. RESULTS Granuloma formation in the conjunctiva can occur following lodgment of an insect wing. This can cause the patient chronic redness, discharge, and discomfort. CONCLUSIONS Small foreign bodies with relatively little mass and large surface area can evade the normal protective mechanisms for removal of a foreign body and give rise to a chronic inflammatory response.
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Affiliation(s)
- Pradeep Venkatesh
- Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
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Abstract
BACKGROUND Conjunctival amyloidosis is a rare entity, which can present with epiphora. The management options, including the surgical treatment of this disease, are illustrated with a case study. METHODS A combination of retrospective and prospective review of a patient's clinical findings, course and treatment outcome. RESULTS A middle-aged patient with epiphora due to localized conjunctival amyloidosis is described. The clinical course of the epiphora during a 10-year period revealed a decrease on the initially symptomatic side and involvement of the opposite side despite bilateral progressive lacrimal drainage stenosis. The pathophysiology of this phenomenon is discussed. The progressive conjunctival deposits in this patient eventually required operative debulking through a conjunctival approach. Medial ectropion and punctal stenoses were also simultaneously corrected. The patient became symptom free one week after these operative interventions. CONCLUSIONS Localized conjunctival amyloidosis is a chronic, slowly progressive disease, which is frequently bilateral. Associated ocular involvement does not seem to be a part of this disease, even with long-term follow-up. The treatment of associated epiphora requires an organized approach to the underlying cause(s). The epiphora may be managed by a staged correction of its pathogenic mechanisms.
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Affiliation(s)
- Farhad Pirouzmand
- Oculoplastic service, Department of Ophthalmology, University of Toronto, Toronto, Canada
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Shields JA, Eagle RC, Shields CL, Green M, Singh AD. Systemic amyloidosis presenting as a mass of the conjunctival semilunar fold. Am J Ophthalmol 2000; 130:523-5. [PMID: 11024429 DOI: 10.1016/s0002-9394(00)00567-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To report a case of systemic amyloidosis that presented as a mass of the plica semilunaris (semilunar fold) of the conjunctiva. METHODS Case report. RESULTS A healthy 56-year-old man developed a fleshy, hemorrhagic lesion of the semilunar fold of the left conjunctiva. Excisional biopsy revealed an acellular lesion of the conjunctival stroma that stained positively for Congo red and showed apple-green birefringence and dichroism with polarization microscopy. The diagnosis was amyloidosis of the semilunar fold of the conjunctiva. Subsequent evaluation disclosed systemic amyloidosis. The patient remains asymptomatic. CONCLUSIONS Although conjunctival amyloidosis usually occurs as a localized lesion without systemic involvement, it can be the initial sign of systemic amyloidosis.
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Affiliation(s)
- J A Shields
- Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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O'Donnell B, Wuebbolt G, Collin R. Primary (localised non-familial) conjunctival amyloidosis. Eye (Lond) 1999; 12 ( Pt 5):902. [PMID: 10070538 DOI: 10.1038/eye.1998.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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