Ocular-Predominant Waldenström Macroglobulinemia Presenting With Subconjunctival Hemorrhage, Diffuse Roth Spots, and Bilateral Neurosensory Retinal Detachment: A Case Report

Waldenström macroglobulinemia (WM) is a rare lymphoplasmacytic lymphoma characterized by bone marrow infiltration and monoclonal immunoglobulin M (IgM) production.Ophthalmologic findings as the initial manifestation are uncommon.A 66-year-old man presented with sudden-onset left subconjunctival hemorrhage, ocular pruritus, and reduced visual acuity (VA).Fundoscopy revealed bilateral diffuse retinal hemorrhages with 360-degree Roth spots, neurosensory retinal detachment, and macular edema.Laboratory evaluation showed normocytic anemia, thrombocytopenia, and an IgM-kappa monoclonal protein (serum IgM: 5,040 mg/dL; reference range: 40-230 mg/dL); imaging demonstrated splenomegaly and lymphadenopathy.Bone marrow biopsy supported the diagnosis of WM.The course was complicated by hyperviscosity, hyperuricemia, and cytomegalovirus (CMV) reactivation.Therapeutic plasma exchange and systemic therapy achieved marked hematologic response; however, neurosensory retinal detachment persisted despite a single intravitreal aflibercept 2 mg in each eye.This case represents an unusual ocularpredominant presentation of WM.Roth spots, retinal hemorrhages, and neurosensory retinal detachment, particularly with cytopenias or hyperproteinemia, should prompt investigation for systemic hematologic disease.Visual recovery may remain incomplete despite adequate hematologic response.