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A 63-year-old man was seen with decreased vision in both eyes. He had been diagnosed as having type 2 diabetes for 10 years. His visual acuity was 20/40 OU. Fundus examination showed venous dilatation, retinal hemorrhages, hard exudates, and serous macular detachment (arrowheads) (Figure 1). Optical coherence tomography scans showed intraretinal fluid accumulation with serous macular detachment in both eyes. He was diagnosed as having nonproliferative diabetic retinopathy with macular edema in both eyes. He received 3 intravitreal bevacizumab injections at 4 weekly intervals and 2 intravitreal triamcinalone acetonide injections in both eyes, with minimal resolution of edema. Blood analysis revealed a low hemoglobin level of 8 g/dL, red blood cell count of 3.3 × 106/μL, white blood cell count of 3460/μL (15% neutrophils, 84% lymphocytes, and 1% monocytes), fasting blood glucose level of 120 mg/dL, normal lipid profile, serum urea nitrogen level of 45 mg/dL, and an increased serum creatinine level of 1.4 mg/dL (to convert hemoglobin to grams per liter, multiply by 10.0; red blood cell count to ×1012 per liter, multiply by 1.0; white blood cell count to ×109 per liter, multiply by 0.001; blood glucose to millimoles per liter, multiply by 0.0555; serum urea nitrogen to millimoles per liter, multiply by 0.357; and serum creatinine to micromoles per liter, multiply by 88.4).
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C. Do plasma electrophoresis and bone marrow analysis
This patient’s blood analysis revealed anemia, an increased white blood cell count with lymphocytosis, and an elevated serum creatinine level. All of these pointed to an underlying hyperviscosity syndrome secondary to a systemic disease. Nonresponse to antipermeability agents was also consistent with a nondiabetic etiology. Bone marrow study showed plasmacytosis (30%). Serum electrophoresis revealed an M-protein spike. A diagnosis of multiple myeloma with paraproteinemic maculopathy was made, and the patient was started chemotherapy. However, within weeks of starting the therapy, the patient had a cerebrovascular accident.
Paraproteinemia is a monoclonal gammopathy. It encompasses diseases like multiple myeloma, Waldenström macroglobulinemia, and cryoglobulinemia. Excess immunoglobulins in the blood lead to hyperviscosity.1 Multiple myeloma is a plasma cell dyscrasia characterized by high levels of a paraprotein called monoclonal protein, or M protein, in the blood and urine. Major organ systems involved in hyperviscosity syndromes include eye, heart (congestive heart failure), and brain (cerebrovascular accidents).
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Corresponding Author: Pratyusha Ganne, MS, Aravind Eye Hospital, Cuddalore Road, Puducherry 605007, India (email@example.com).
Published Online: May 10, 2018. doi:10.1001/jamaophthalmol.2017.6285
Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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