corneal and conjunctival changes in...

August 1969 Volume 8, Number 4

INVESTIGATIVE OPHTHALMOLOGY

Corneal and conjunctival changesin dysproteinemia

7?. M. H. Pinkerton and David M. Robertson

A case of dysproteinemia with corneal and conjunctival crystalline changes is described.These crystalline changes were found to be caused by stromal infiltration of the cornea andconjunctiva by cells containing numerous crystallike deposits in their cytoplasm. Morphologi-cally identical crystals were found in abundance in plasma cells of the bone marrow.

Key words: multiple myeloma, corneal infiltrate, corneal stroma,conjunctiva, crystalline deposits, bone marrow cells, corneal birefringence,

histopathology, electron microscopy, light microscopy.

-he clinical features of corneal and con-junctival changes in multiple myeloma andother dysproteinemias have been describedby Duke-Elder,1 Aronson and Shaw,2 andFrancois and Rabaey.3 These changes areseen infrequently, and many review articleson the ocular complications of multiplemyeloma do not mention them. Aronsonand Shaw, in an attempt to assess the in-cidence of the findings, reviewed 13 pa-tients with myeloma, none of whom hadcorneal and conjunctival changes.

We report herein a case in which thelight and electron microscopic appearanceof refractile deposits in the cornea and con-junctiva were studied.

Review of a caseHistory. A. R., a 50-year-old man, was

hospitalized because of anemia and renal

From the Departments of Ophthalmology andPathology, Queens University and the KingstonGeneral Hospital, Kingston, Ontario, Canada.

Manuscript submitted July 11, 1968; manuscriptaccepted Sept. 10, 1968.

failure. Investigation revealed the followingfindings: (1) The erythrocyte sedimenta-tion rate (ESR) was 115 mm. in the firsthour. (2) Plasma electrophoresis showeda sharp peak of gamma globulin. Six gramsof immunoglobulin G were found in theurine per day (Fig. 1). (3) Seven per centplasma cells appeared in the bone marrowwith rather immature nuclei. (4) Boneswere shown to be radiologically normal.The diagnosis was dysproteinemia, proba-bly of the multiple myeloma type.

Ophthalmological history. Two years agothe patient had a sudden loss of visualacuity in the left eye which was thoughtto be caused by anterior uveitis. This haddisappeared almost completely after 2weeks of treatment with atropine and topi-cal steroids. In the intervening 2 years hehad 3 to 4 similar episodes. The right eyehad never been affected. On examinationthere were diffuse deposits of fine irides-cent crystalline bodies in the cornea andconjunctiva of both eyes. These were seenmost easily in the corneal stroma and werefairly evenly distributed throughout it (Fig.

357

Downloaded From: http://iovs.arvojournals.org/pdfaccess.ashx?url=/data/journals/iovs/933003/ on 06/14/2018

358 Pinkerton and Robertson Investigative OphthalmologyAugust 1969

Fraction

ALBUMIN

Glo

bu

lin

s fltv

1*-

TOTAL

Count

38

3

8

11

8

37

105

Total Protein 7. 5

%

36. 2

2 .9

7.6

10. 5

7.6

35.2

100

Fig. 1. Results of serum electrophoresis.

2). They appeared as glistening specks onthe bulbar conjunctiva. On the left therewere some old keratic precipitates on theback of the cornea; the anterior chamberhad no cells or flare, and the anterior seg-ment was otherwise unremarkable. The vit-reous on the left was hazy, more marked in-feriorly. This haze was due to innumerableyellowish-white, dustlike opacities. Thefundus could be seen past these, and noabnormality of the retina could be de-tected. Those areas of the peripheral retinaand pars plana which could be visualizeddid not show any abnormality, but the areabehind the vitreous opacity inferiorly couldnot be visualized. There was no abnormal-ity of the posterior segment on the right.A keratoconjunctival biopsy was taken fromthe left eye in an effort to elucidate thehistology of the corneoconjunctival de-posits. This consisted of a thin lamellarfragment of the peripheral cornea with itsadjacent conjunctiva.

Methods

Portions of excised conjunctiva and cornea wereplaced immediately in phosphate-buffered 3 percent glutaraldehyde. After fixation for 3 hours,

small blocks were cut, washed in phosphate buffer,postfixed in 1 per cent osmium tetroxide for onehour, dehydrated, and embedded in epon. Theremainder of the tissue was dehydrated and em-bedded in paraffin following a brief phosphatewash.

For light microscopy paraffin sections werestained with hematoxylin-phloxine-saffron andperiodic acid-Schiff (PAS) -hematoxylin; eponsections were stained with alkaline toluidine blue.Thin sections for electron microscopy weredoubly stained with uranyl acetate and leadcitrate.

Light microscopy. The conjunctiva appearedmildly edematous. Scattered among the collagenfibers in the subepithelial tissues were smallnumbers of cells, either singly or in small clusters,with irregular outlines, abundant pale-staining,eosinophilic cytoplasm and small dense-staining,frequently eccentric, nuclei (Fig. 3). Within theircytoplasm were numerous poorly defined needle-like unstained clefts, several microns long andabout 0.5 p. in width; the cleft were weakly bi-refringent and PAS-negative (Fig. 4).

The conjunctival epithelium and the portion ofsuperficial cornea which were studied were essen-tially unremarkable.

Half-micron sections of glutaraldehyde-fixed,osmium tetroxide-stabilized, epon-embedded tis-sue stained with toluidine blue showed the intra-cellular deposits more clearly as dense blue-black,sharply defined "needles" often arranged in paral-lel aggregates within individual cells (Fig. 5).


Volume 8Number 4

Dysproteinemia 359

Fig. 2. Slit-lamp photograph of typical corneal findings.


Volume 8Number 4

Dysproteinemia 361

• • • *•

- *

Fig. 3. Conjunctiva. Epithelium is essentially intact; in the stroma are small clusters (arrows)of cells with abundant cytoplasm and small dense nuclei. (Paraffin; hematoxylin-phloxine-saffron (HPS); xl50.)

^ #

Fig. 4. Higher magnification of Fig. 3. Within the cytoplasm of the abnormal cells are nu-merous small randomly arranged needlelike clefts. (Paraffin; HPS; x475.)

Very occasional deposits appeared to be extra-cellular. None were found in the corneal frag-ments.

Electron microscopy. Electron microscopic studyof this tissue was limited by the poor quality oftissue preservation. The subconjunctival cells con-taining the deposits were characterized by densecytoplasm which contained numerous free ribo-somes (Fig. 6) and occasionally by a rich arrayof granular endoplasmic reticulum reminiscent ofthat seen in plasma cells. Most of the inclusion-

bearing cells did not, however, have the morpho-logical features characteristic of mature plasmacells, and their identity remains in question. De-posits ranged in size from 0.05 to 0.4 A in width,and, in the plane of section, from 0.5 to 7 fi inlength. The largest crystals appeared to be freein the cytoplasm, but smaller ones were oftensurrounded by a membrane apparently derivedfrom the endoplasmic reticulum (Fig. 7). In thecornea a very few crystals were found, again incells with abundant ribosomes and distinct from



Fig. 5. In osmium-stained material, the deposits are well preserved and appear as closelypacked crystallike densities filling the cytoplasm of the involved cells. (Epon; toluidine blue;xl,550.)

mFig. 6. Conjunctival cell with deposits. The cell exhibits numerous fine pseudopodia and hasdense cytoplasm containing numerous ribosomes, several poorly preserved profiles of endo-plasmic reticulum, and scant mitochondria. The deposits appear as long narrow relativelyhomogenous masses with angular or blunt ends and parallel sides. They vary greatly in sizeand shape.


Volume 8Number 4

Dysproteinemia 363

Fig. 7. Conjunctival deposits. Several of the smaller deposits are enclosed in a rather poorlydefined, interrupted (artifactually) membrane which loosely follows their contours. No in-ternal structure is seen.

Fig. 8. Bone marrow. A cell with prominent highly organized granular endoplasmic reticulunilike that of plasma cells contains deposits like those in the cornea.



the corneal stromal cells which appeared normal.A true crystalline substructure was not demon-

strated. The crystals had blunt, angular ends andstraight parallel sides with occasional deformitiessuggestive of "fracture."

In the bone marrow, numerous cells containedapparently identical deposits. The majority ofthese cells had morphological features indicativeof their being plasma cells0 (Fig. 8).

Discussion

Multiple myeloma is one of the clinicalforms of the plasma cell dyscrasias. Thisgroup is characterized by: (1) proliferationof plasma cells in the absence of identifi-able antigenic stimulation, (2) the elabora-tion of electrophoretically and structurallyhomogenous M type gamma globulin orsubunits of this, and (3) associated defi-ciency in synthesis of normal immunoglobu-lins.5

Several morphological types of inclusions,both in cytoplasm and nucleus, have beenfound in marrow and lymph node cells inmultiple myeloma and the other forms ofdysproteinemia. Their appearances werebriefly reviewed by Maldonado and asso-ciates4 in 1966. The cytoplasmic depositshave been either amorphous or crystallineand located both within and outside thecisterns of endoplasmic reticulum. Theirvaried morphology and staining reactionsin different cases probably reflects the bio-chemical variability of the abnormal circu-lating proteins in this group of conditions.

Two types of changes have been de-scribed in the cornea in multiple myeloma:(1) the crystalline form, and (2) the deepdystrophic form (Francois and Rabaey).3

Pathological studies of the crystalline formhave been undertaken by Aronson andShaw.2 They describe finding many crys-talloid structures in the cytoplasm in 10per cent of the myeloma cells of the bonemarrow. These were best visualized with

phase microscopy. An attempt was made tofind these in a bulbar conjunctival biopsy,but no birefringent element could be de-tected in this specimen. However, furthersections were thought to reveal the pres-ence of lipoids in the conjunctiva. In thedeep dystrophic type the posterior onethird of the corneal stroma was replacedby a hyaline mass with almost completeloss of the normal collagen structure in thisarea except for a narrow strip posteriorly.The nature of this hyaline mass was notestablished, but it was proposed that it wasglobulin in nature.

Our case shows typical crystalline cornealand conjunctival change in dysproteinemia.This is seen to be due to the stromal in-filtration by cells which contain crystals.This gives rise to the birefringence andclinical iridescence. Similar cells were iden-tified in the bone marrow by both lightand electron microscopy.

The authors wish to thank Dr. P. R. Galbraithfor referring this patient for examination.

REFERENCES1. Duke-Elder, S.: System of ophthalmology,

Vol. Ill, St. Louis, 1965, The C. V. MosbyCompany, p. 1091.

2. Aronson, S. B., and Shaw, R.: Corneal crystalsin multiple myeloma, Arch. Ophth. 61: 541,1959.

3. Francois, J., and Rabaey, M.: Corneal dys-trophy in paraproteinemia, Am. J. Ophth. 52:895, 1961.

4. Maldonado, J. E., Brown, A. L., Jr., andBayrd, E. D.: Cytoplasmic and intranuclearelectron-dense bodies in the myeloma cell,Arch. Path. 81: 484, 1966.

5. Osserman, E. F.: Plasma cell dyscrasia, inCecil, R. L., and Loeb, R. F., editors, Text-book of medicine, ed. 12, Philadelphia, 1967,W. B. Saunders Company, p. 1101.

6. Argani, I , and Kipkie, G. F.: The cellularorigin of macroglobulins. A study of the pro-tein-secreting cells in Waldenstrom's disease,Lab. Investig. 14: 720, 1965.


corneal and conjunctival changes in...

Documents