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| Year : 2021 | Volume
: 67
| Issue : 1 | Page : 51-52 |
Drusen-like deposits in a patient with multiple myeloma
S Handa, V Gupta, A Agarwal
Department of Ophthalmology, Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| Date of Submission | 04-May-2020 |
| Date of Decision | 02-Sep-2020 |
| Date of Acceptance | 11-Sep-2020 |
| Date of Web Publication | 09-Jan-2021 |
Correspondence Address:
A Agarwal
Department of Ophthalmology, Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpgm.JPGM_461_20
How to cite this article:
Handa S, Gupta V, Agarwal A. Drusen-like deposits in a patient with multiple myeloma. J Postgrad Med 2021;67:51-2 |
A 57-year-old male was diagnosed with multiple myeloma (MM) with renal involvement and was initiated on chemotherapy (cyclophosphamide, thalidomide, and dexamethasone). The patient complained of recent-onset metamorphopsia in the left eye. Best-corrected visual acuity was 20/60 in both eyes. Anterior segment examination in both eyes revealed nuclear sclerosis grade 1. On posterior segment examination, there was presence of yellowish drusen-like deposits in the peripapillary region in the right eye and the foveal center in the left eye. On the near-infrared reflectance image, hyper-reflective changes were visible in the areas affected by drusen-like deposits. The horizontal spectral-domain optical coherence tomography scan showed the presence of drusen-like deposits that wrinkled the overlying retinal pigment epithelium [Figure 1]. Fundus autofluorescence imaging ruled out true drusen [Figure 2]. The patient was kept under follow-up with no intervention, and called for review after 3 months. | Figure 1: (a) Fundus photograph of the right eye of the patient shows normal-looking optic nerve head and vessels. There are subtle subretinal pigmentary changes in the temporal peripapillary region. (b) The near-infrared scan and corresponding spectral-domain optical coherence tomography (SD-OCT) shows drusen-like deposits (white arrowheads) and elevation of the retinal pigment epithelium (RPE). (c) Fundus photograph of the left eye shows macular yellowish lesions that are hyper-reflective on near-infrared imaging; and (d) appear as RPE elevations on SD-OCT (white arrowheads)
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 | Figure 2: (a and b) Fundus autofluorescence imaging of both eyes show the absence of altered autofluorescence signal that would occur in cases with true drusen. This indicates the presence of drusen-like deposits
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Such drusen-like deposits can occur in various systemic conditions that are associated with complement activation and renal disorders. Various ocular manifestations of MM have been described in literature. These include crystalline keratopathy, ciliary body cysts, and features of hyperviscosity like dilated, tortuous veins, sludging of retinal vessels, retinal hemorrhage, microaneurysms, and cotton wool spots.[1] Drusen-like deposits have not been previously reported in MM. In other diseases that affect the kidneys (apart from MM) such as systemic lupus erythematosus, such drusen-like deposits can be observed on fundus imaging.[2] Similarities exist between the choriocapillaris and the fenestrated capillaries of the glomeruli.[3] Several histopathologic investigations have demonstrated the presence of complement components in age-related drusen as well as in glomerulonephritis associated drusen-like deposits. There exists a possible role of complement activation/deposition or complement pathway abnormalities in the formation of drusen and drusen-like deposits.[4] Most common renal complication in MM include monoclonal immunoglobulin deposition disease. Monoclonal immunoglobulins, through the interference of the complement alternative pathway, have been shown to play the synergistic role towards renal damage.[5] C3 deposition in glomeruli and serum C3 hypocomplementemia has been described in a MM patient with renal involvement.[5] Since complement abnormalities have been reported in patients with MM, we hypothesize that the complement factor could play a major role in the development of drusen-like deposits in our patient. Age-related drusen are generally distributed diffusely across central and peripheral retina. In our case, however, the drusen-like deposits were fairly localized (peripapillary location in right eye and subfoveal in left eye) which suggests that these deposits were unlikely due to age-related changes. In addition, recent-onset metamorphopsia suggests that the pathology is recent in onset. Identification of drusen-like deposits in a MM patient may point toward renal involvement. Thus, detailed ocular examination and multimodal imaging evaluation is an important adjunct to systemic examination for screening of renal disease by detection of drusen-like deposits.
Declaration of patient consent
The authors certify that appropriate patient consent was obtained.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| :: References | |  |
| 1. | Knapp AJ, Gartner S, Henkind P. Multiple myeloma and its ocular manifestations. Surv Ophthalmol 1987;31:343-51.  |
| 2. | Invernizzi A, dell'Arti L, Leone G, Galimberti D, Garoli E, Moroni G, et al. Drusen-like deposits in young adults diagnosed with systemic lupus erythematosus. Am J Ophthalmol 2017;175:68-76. |
| 3. | Khan KN, Mahroo OA, Khan RS, Mohamed MD, McKibbin M, Bird A, et al. Differentiating drusen: Drusen and drusen-like appearances associated with ageing, age related macular degeneration, inherited eye disease and other pathological processes. Progress Retin Eye Res 2016:1-37. |
| 4. | Mullins RF, Aptsiauri N, Hageman GS. Structure and composition of drusen associated with glomerulonephritis: Implications for the role of complement activation in drusen biogenesis. Eye 2001;15:390-5. |
| 5. | Khan A, Lam K, El-Sayegh S, El-Charabaty E. A case of myeloma kidney with glomerular C3 deposition. World J Nephrol Urol 2018;7:73-7. |
[Figure 1], [Figure 2]
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