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   Table of Contents      
ARTICLES
Year : 1971  |  Volume : 19  |  Issue : 4  |  Page : 177-181

Bilateral orbital involvement in multiple myelomatosis


1 Dept. of Ophthalmology, Medical College and Hospital, Rohtak, India
2 Dept. of Pathology, Medical College and Hospital, Rohtak, India
3 Dept. of Radiology, Medical College and Hospital, Rohtak, India

Correspondence Address:
B S Chohan
Dept. of Ophthalmology, Medical College and Hospital, Rohtak
India
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Source of Support: None, Conflict of Interest: None


PMID: 15745416

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How to cite this article:
Chohan B S, Parmar I, Chugh T D, Jain A L. Bilateral orbital involvement in multiple myelomatosis. Indian J Ophthalmol 1971;19:177-81

How to cite this URL:
Chohan B S, Parmar I, Chugh T D, Jain A L. Bilateral orbital involvement in multiple myelomatosis. Indian J Ophthalmol [serial online] 1971 [cited 2020 May 28];19:177-81. Available from: http://www.ijo.in/text.asp?1971/19/4/177/34970

Multiple myeloma is a bone tumour of multicentric origin characterised by pain, pathologi­cal fractures and anaemia. The bones commonly involved are the ribs, sternum, clavical, vertebral bodies, pelvis and occasionally the skull; long bones may be affected but never alone. Ocular involve­ment in multiple myelomatosis has been described in a small, number of cases in ophthalmic literature.

Such involvement has been re­ported by Clarke

Tilk Ram, a male aged 45 years was admitted to this hospital in October, 1968, with gradually increasing swelling of the right orbit for 8 months prior to admis­sion.

The patient experienced also generalised weakness and pains in the whole of his body. Two months before admission he start­ed feeling moderate pain in the left also. The patient developed symptoms of acute confusianal state during his stay in the hospi­tal. He had small-pox infection at the age of 10 years when he had lost his left eye.

General physical examination showed anaemia and marked emaciation of the whole body with generalised tenderness of the the chest bones and the spine. Except in the right orbital region, no other swelling was noticed any­where on the body. Small-pox scar marks were seen sparsely distributed all over. No abormali­ty was detected in cardiovascular respiratory, central nervous sys­tem and gastro-intestinal tract.


  Examination Top


The right eye showed a forward, downward and inward displace­ment of the eyeball [Figure - 1]. The proptosis was non-compressible, non-pulsatile and slight tender­ness was present on its upper and outer extent. The proptosis was due to two almond shaped swell­ings situated in the superolateral and inferolateral orbital margins which were extending to the right temporal region. The skin over the swellings was mobile. Mild pressure on the eyelids resulted in subluxation of the eye. Move­ments of the eyeball were restrict­ed in upper, outer and lower directions. The conjunctiva show­ed moderate pale white chemosis. Slight xerosis of the lower third of the cornea was present. The pupil reacted sluggishly to light and accommodation. Examina­tion of the fundus could not be done because of marked haziness of the vitreous, The vision gradu­ally deteriorated.

The left eye showed enophthal­mos due to phthisis bulbi with calcified spots over the corneal surface. On Eversion of the upper lid a small nodular swelling was visible in the left fornix. It was difficult to reach its posterior limit. The swelling was separate from the eyeball. The movements of the eyeball were negligible. There was no obvious displace­ment of the eye.

Radiological examination:

The right orbital cavity was en­larged and there was extensive bony erosion of the superior and lateral orbital margins with slight rarefaction of the orbital plate of the frontal bone. A small translu­cent punched out area was seen in the region of the greater wing of the sphenoid. The left orbit show­ed a large translucent area and rarefaction in the orbital plate of the frontal bone. A small bony erosion was observed near the superomedial margin of the orbi­tal rim. The cavity was not anal in size. In the skull, generalised rarefaction with numerous round­ed discrete translucent areas of varying sizes were shown [Figure - 2].

The examination of the -pine, chest bones and the pelvis show­ed generalised rarefaction with characteristic multiple punched out translucencies. Few punched out osteolytic and rarefied areas were also seen in the long bones of the upper and the lower extre­mities. Pathological fractures were seen at the upper end of the left fibula and the third lumbar vertebra.


  Laboratory Findings Top


Haemoglobin was 8 gm%. total lucocytic count 10,000/cmm with a differential count of 65% poly­morphs, 25% lymphocytes, 7% monocytes and 3% eosinophils. Peripheral blood film showed in­creased roulaux formation of red cells and a moderate degree of hypochromia. No immature cells were seen. Platelets were normal in number and morphology. Bleeding and clotting time were within normal limits. Urine exa­mination showed albuminuria (3 plus) and several hyaline and granular casts. Bence-Jones pro­teins were absent on repeated examinations. Total serum pro­teins were 7.5 gm% with albumin 3.4%. alpha, 0.35 gm%, alpha, 0.35 gm%, Beta 0.2 gm%, Gamma 3.2 gm%. No myeloma proteins were seen. Serum calcium was 11.2 mgm%.


  Histopathological Examination Top


The biopsy material consisted of a few small soft tissue pieces. Hoematoscylin eosin stained para­ffin section showed sheets and groups of tumour cells ovoid to polygonal in shape with a mode­rate amount of cytoplasm, each having a single usually large and eccentric nucleus [Figure - 3]. Chro­matin pattern in some of the cells showed a typical cartwheel ar­rangement. Occasional cells also showed a para-nuclear vacuole or nucleolus. A rare mitotic figure of binucleated cell was also seen.


  Sternal Marrow Examination Top


Cellularity was moderately good with a M.E. ratio of 3:1 Numerous myeloma cells and mature plasma cells either in clumps or singly were seen [Figure - 4]). The reaction was normoblastic.


  Treatment Top


Apart from supportive treat­ment in the form of repeated blood transfubions no other form of treatment was considered worthwhile in view of the exten­sive involvement of the skeletal system. Radiotherapy to the pro­ptosed eye was also withheld con­sidering the existing visual dis­ability as a result of previous phthisis bulbi in the other eye. Operative interference was aban­doned because of diffuse infiltra­tion of myelomatous deposits in the orbits and deteriorating con­dition of the patient.


  Comments Top


In view of the presence of ec­centric proptosis with marked generalised cachexia and anaemia the possibilities of a malignancy with secondaries in the orbit and a primary growth of lacrimal gland were initially considered. Multiple myelomatosis was not thought of since the involvement of the orbit in this disease is ex­tremely rare. However, since the patient complained of generalised bone pains and as no eviden' e of a growth elsewhere was found on physical examination, skiagrazns of the skeletal system were taken to exclude this disease. The x-­rays revealed typical bone invol­vement of myelomatosis and the diagnosis was ultimately confirm­ed by other investigations.

The patient had enophthalmos of the left eye which had result­ed from phthisis bulbi due to previous small-pox infection. Since there was no obvious swel­ling in this eye the involvement of the left orbit was missed-ini­tially. Moreover in none of the reported cases of myelomatosis bilateral orbital involvement has been described. In the present case however, subsequent exa­mination revealed a small nodular swelling in the upper fornix which was confirmed on radiological and histopathological examinations to be due to myelomatous deposit. This therefore, probably is the only reported case in recent oph­thalmic literature showing a bila­teral orbital involvement.


  Summary Top


Orbital involvement in multiple myelomatosis is rare and only seventeen cases have been reported in the available literature. A case with bilateral involvement of the orbit is reported[4].

 
  References Top

1.
CLARKE, E. Plasma cell myeloma of the orbit. Brit. J. Ophthal, 37: 543-554, (1953).  Back to cited text no. 1
    
2.
HANDOUSA, A. Multiple myelo­matosis with proptosis. Brit. J. Ophthal., 39: 41-43, (1955).  Back to cited text no. 2
    
3.
KOJIMA, K; SHIMIZUS; AWAYA, S; TANBAT; TAKAYANAGI, A case of orbital myeloma. J. Clin. Ophth. (Tokyo)., 16: 51-55. (1562)  Back to cited text no. 3
    
4.
ROSE AND TAYLOR, Multiple myelomatosis affecting the orbit. Brit. J. Ophthal. 41: 438-439. (1957).  Back to cited text no. 4
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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