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.

MULTIMODAL IMAGING OF RECURRENT CYSTOID MACULAR EDEMA ASSOCIATED WITH POEMS SYNDROME RESPONSIVE TO INTRAVITREAL DEXAMETHASONE IMPLANT

PURPOSE

To describe the multimodal imaging findings of cystoid macular edema (CME) in POEMS syndrome and to demonstrate the effectiveness of the dexamethasone intravitreal implant in this condition.

METHODS

A case report of a patient with POEMS syndrome. Multimodal imaging, including optical coherence tomography and ultra-wide field fluorescein angiography, was used to evaluate the CME and its response to treatment.

RESULTS

A 66-year-old man with a history of POEMS syndrome in clinical remission after chemotherapy presented with blurry vision in the left eye. Vitreomacular traction and CME were noted on optical coherence tomography. After pars plana vitrectomy, the patient had persistent CME in the left eye and developed new CME in the right eye, which worsened over the next year. Visual acuities at this time were 20 of 60 in both eyes. The CME was unresponsive to topical ketorolac and prednisolone acetate and intravitreal bevacizumab but partially response to intravitreal and sub-Tenon's triamcinolone acetate injections. Intravitreal dexamethasone implant was given bilaterally with full resolution and visual acuities improvement to 20 of 40 in the right eye and 20 of 30 in the left eye. However, CME recurred after 3 months. Ultra-wide field fluorescein angiography demonstrated bilateral CME and diffuse peripheral vascular leakage. Serum vascular endothelial growth factor levels were normal.

CONCLUSION

Cystoid macular edema may develop in POEMS syndrome in the absence of systemic findings, elevated serum vascular endothelial growth factor, or optic nerve edema. Previously unreported peripheral vascular leakage was demonstrated on ultra-wide field fluorescein angiography. Dexamethasone implant was the most effective of used therapies to treat CME.

Local Treatment with Triamcinolone Acetonide and Bevacizumab for Ocular Symptoms in a Patient with POEMS Syndrome

PURPOSE

To report our experience in managing a case of bilateral optic disc oedema and unilateral cystoid macular oedema with a posterior subtenon (PST) injection of triamcinolone acetonide and intravitreal bevacizumab (IVB) in a patient with polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome.

CASE REPORT

A 50-year-old healthy woman complaining of bilateral blurred vision for several days was referred to the ophthalmologist. An eye examination showed a bilateral optic disc swelling and small preretinal haemorrhages. In addition, a peripheral neuropathy was found. Laboratory tests showed elevated levels of M-protein type IgA of 1.4 g/l and a vascular endothelial growth factor (VEGF) concentration of 6.1 ng/ml. The cerebrospinal fluid protein content was 131 mg/dl. An abdominal CT scan revealed hepatosplenomegaly. The diagnosis of POEMS syndrome was made based on the polyneuropathy, hepatosplenomegaly, IgA lambda monoclonal proteinemia, and optic disc swelling. As vision declined, 40 mg PST injection of triamcinolone was given bilaterally. Ten weeks thereafter, 2 IVB injections of 2.5 mg were administered to the left eye, with a 4-week interval. Because of an incomplete recovery of her visual functions, diarrhoea and general malaise, melphalan, followed by autologous peripheral blood stem cell transplantation, was initiated. After systemic treatment, she had no visual complaints anymore, the optic disc oedema had resolved, and the VEGF serum concentration had normalized.

DISCUSSION

Local treatment with IVB and PST injection of triamcinolone can be an option for ocular symptoms in POEMS syndrome. However, given the incomplete recovery of the ocular abnormalities and the other symptoms, systemic treatment remains standard.

Blood pressure treatment in acute ischemic stroke: a review of studies and recommendations

PURPOSE OF REVIEW

Elevated blood pressure (BP) is frequent in patients with acute ischemic stroke. Pathophysiological data support its usefulness to maintain adequate perfusion of the ischemic penumba. This review article aims to summarize the available evidence from clinical studies that examined the prognostic role of BP during the acute phase of ischemic stroke and intervention studies that assessed the efficacy of active BP alteration.

RECENT FINDINGS

We found 34 observational studies (33,470 patients), with results being inconsistent among the studies; most studies reported a negative association between increased levels of BP and clinical outcome, whereas a few studies showed clinical improvement with higher BP levels, clinical deterioration with decreased BP, or no association at all. Similarly, the conclusions drawn by the 18 intervention studies included in this review (1637 patients) were also heterogeneous. Very recent clinical data suggest a possible beneficial effect of early treatment with some antihypertensives on late clinical outcome.

SUMMARY

Observational and interventional studies of management of acute poststroke hypertension yield conflicting results. We discuss different explanations that may account for this and discuss the current guidelines and pathophysiological considerations for the management of acute poststroke hypertension.