In July 2006 it was noted that the yellow-orange material started to break up in both eyes and then, progressively, disappeared; in October 2006 it was nearly undetectable (). At this stage, visual acuity was 20/126, N10 right eye (OD) and 20/126, N12 left eye (OS). Concurrently, as the material disappeared clinically, multiple small foci of very highly increased autofluorescence appeared ().
Figure 2 Fundus appearance and autofluorescence findings 18 months following the initial visit (October 2006, see text). (A) Colour fundus photographs show disappearance of most of the subretinal material. (B) Autofluorescence imaging demonstrates small foci of (more ...)
In April 2007, only mild retinal pigment epithelial (RPE) changes were seen clinically at the macula but few retinal haemorrhages were present and, thus, blood work-up was arranged. On serum protein electrophoresis, a paraprotein band, typed as immunoglobulin G (IgG) and measuring 12 g/l, was detected. Serum IgG level was 21 g/l (normal range 6–16). Bone marrow biopsy disclosed 25% plasma cells with aggregates of small atypical plasma cells. At this stage, the diagnosis of stage II (South West Oncology Group staging) multiple myeloma was made. Treatment with melphalan and thalidomide was given. This treatment did not appear to modify the further progression of the macular lesions.
In April 2008, fundus examination remained unchanged. A mildly increased autofluorescence signal was evident in the right eye () and optical coherence tomography demonstrated a lack of foveal depression and minimal amount of subretinal fluid (). In the left eye, areas of reduced autofluorescence signal and few remaining foci of increased AF were seen; optical coherence tomography demonstrated a neurosensory retinal detachment at the site previously occupied by the pseudovitelliform lesions ().
Little change was noted in the fundus appearance until May 2009 when bilateral neurosensory retinal detachments were noted on fundus examination and optical coherence tomography (). At this stage, hyperfluorescence was observed on fluorescein angiography bilaterally (). Treatment with oral acetazolamide (250 mg twice a day) was given in an attempt to reduce/resolve the subretinal fluid; however, no response at this stage of the disease was observed. The systemic status of the patient had remained unchanged with no progression of the multiple myeloma detected.
Fluorescein angiography and optical coherence tomography findings on May 2009. (A) Leakage was observed at the macula on fluorescein angiography and (B) optical coherence tomography disclosed a neurosensory retinal detachment in both eyes.