Copyright 2002 American Medical Association. All Rights Reserved.
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Multiple myeloma is a malignancy of the immune system that infrequently
involves the eye. Cysts of the ciliary body and retinal vascular lesions represent
the most common ocular manifestations in myeloma patients.1
This report documents the first case of anterior chamber infiltration–simulating
hypopyon (pseudohypopyon) in multiple myeloma.
A 72-year-old white man was referred by his hematologists for anterior
segment evaluation. Hyperemia and soreness of his left eye, accompanied by
blurred vision, had been noted over the preceding 3 weeks. The patient had
been diagnosed with multiple myeloma 2 months previously following prolonged
fatigue, acute renal insufficiency, and high levels of serum calcium and IgG.
Subsequently, he received 3 courses of vincristine sulfate, doxorubicin hydrochloride,
and methylprednisolone (VAMP) chemotherapy, which resulted in considerable
decrease of the paraprotein (IgG). His ocular symptoms developed 2 weeks after
the last course of chemotherapy, while he was taking oral amitriptyline hydrochloride,
ciprofloxacin hydrochloride, and acyclovir.
On examination, his corrected visual acuity was 20/30 OD and 20/40 OS.
Both corneas were clear, and his left conjunctiva was hyperemic, although
there was no conjunctival venous sludging. His left pupil was slightly irregular,
and there was evidence of low-grade anterior chamber activity (indicated by
a few cells and mild flare) with secondary localized posterior synechiae.
However, the most striking clinical abnormality was a white, solid, well-demarcated
pseudohypopyon of undetermined source occupying the inferior anterior chamber
and slightly extending medially (Figure 1). There was no evidence of crystals within the cornea or infiltration
of the iris. Intraocular pressures were within normal limits, and ophthalmoscopy
results were unremarkable in both eyes, with the absence of retinal venous
stasis, cotton-wool spots, or optic disc swelling. Although the lesion was
simulating a hypopyon, there was no strong evidence of an infective underlying
cause, so the patient began taking mild topical steroids (0.5% prednisolone
ophthalmic drops, 4 times daily). A sample of the infiltrate was obtained
through a corneal paracentesis. Cytology results confirmed the presence of
monoclonal plasma cell infiltration. The patient underwent 10 courses of radiotherapy
to the left orbit with subsequent complete resolution of the pseudohypopyon
(Figure 2). After treatment began,
the cellular activity in the anterior chamber and the pseudohypopyon resolved,
and the patient's visual acuity improved to 20/30 in the affected eye.
White, solid, anterior chamber
Immunoperoxidase on a cytospin
of fluid revealing κ light chain restriction within a monoclonal population
of plasma cells (original magnification ×320). Courtesy of Alastair
Multiple myeloma is the most common of the plasma cell dyscrasias characterized
by monoclonal gammopathy and osteolytic bone lesions.2
Ocular involvement in patients with multiple myeloma has been well described.1 The ocular manifestations may be divided into 2
groups: those attributable to myeloma infiltration in and about the eye, and
the ocular consequences of hematologic and serum protein abnormalities.3 Bronstein4 reported
plasma cells floating free in the anterior chamber and adhering to the posterior
cornea. Infiltration of the iris has also been reported, simulating a nongranulomatous
uveitis.5 However, to our knowledge, this
is the first report of a myeloma patient with a well-formed, solid infiltrate
in the anterior chamber that resembles a hypopyon (pseudohypopyon). A pseudohypopyon
is characterized by its persistence and irregular contour, which suggest clumping
of neoplastic cellular material rather than the layering of neutrophils, as
in anterior uveitis.
Resolved blood remnants and neoplastic infiltrates may give rise to
a comparable appearance. Neoplastic infiltrates can be caused by acute or
chronic leukemias or juvenile xanthogranuloma, or they may be an atypical
manifestation of retinoblastomas. In addition, metastatic carcinomas of the
iris, which typically appear as solid, amelanotic masses, occasionally are
discohesive and shed cells that form a hypopyon in the anterior chamber.6,7
Treatment of multiple myeloma is predominantly directed toward the systemic
disease, and chemotherapy and radiotherapy are very effective in reducing
the tumor mass.8 In our patient, radiotherapy
resulted in complete resolution of the anterior chamber infiltrate with subsequent
improvement of his visual acuity.
Our case of a solid anterior chamber infiltrate broadens the clinical
spectrum of multiple myeloma and emphasizes that tumor infiltrates should
be considered in the differential diagnosis of any atypical hypopyon. Close
cooperation between the oncologists and ophthalmologists who treat such patients
is mandatory for prompt diagnosis and effective management.
Corresponding author and reprints: Paris G. Tranos, ICO, Department
of Ophthalmology, Royal Free Hospital Medical School, Pond Street, London
NW3 2QG, England (e-mail: email@example.com).
Tranos PG, Andreou PS, Wickremasinghe SS, Brazier JD. Pseudohypopyon as a Feature of Multiple Myeloma. Arch Ophthalmol. 2002;120(1):87-88. doi: