|Year : 2016 | Volume
| Issue : 2 | Page : 157-159
Bilateral macular hemorrhage due to megaloblastic anemia: A rare case report
Sree Kumar Vaggu, Preethi Bhogadi
Department of Ophthalmology, Regional Eye Hospital, Kakatiya Medical College, Warangal, Telangana, India
|Date of Submission||18-Apr-2015|
|Date of Acceptance||04-Oct-2015|
|Date of Web Publication||5-Apr-2016|
Dr. Sree Kumar Vaggu
Regional Eye Hospital, Kakatiya Medical College, Warangal - 506 007, Telangana
Source of Support: None, Conflict of Interest: None
We report a case of a 17-year-old female patient who presented with sudden, painless, nonprogressive diminished vision in both eyes (best corrected visual acuity in right eye - 6/60 and left eye - 6/36). An ophthalmological evaluation revealed bilateral pale tarsal conjunctiva and bilateral macular hemorrhage. Hematological evaluation revealed the presence of megalocytic anemia (with hemoglobin - 4.9 g%). General examination showed severe pallor. On systemic examination, no abnormality was detected, confirmed by ultrasonography abdomen. Other causes of severe anemia have been ruled out. Intraocular pressure in both eyes was 12 mmHg. This case documents the rare occurrence of bilateral subinternal limiting membrane macular hemorrhage with megaloblastic anemia without thrombocytopenia and other retinal features of anemic retinopathy.
Keywords: Anemic retinopathy, bilateral macular hemorrhage, megaloblastic anemia, Vitamin B12 deficiency
|How to cite this article:|
Vaggu SK, Bhogadi P. Bilateral macular hemorrhage due to megaloblastic anemia: A rare case report. Indian J Ophthalmol 2016;64:157-9
|How to cite this URL:|
Vaggu SK, Bhogadi P. Bilateral macular hemorrhage due to megaloblastic anemia: A rare case report. Indian J Ophthalmol [serial online] 2016 [cited 2020 Jan 29];64:157-9. Available from: http://www.ijo.in/text.asp?2016/64/2/157/179720
Bilateral macular hemorrhage alone due to megaloblastic (nutritional) anemia without thrombocytopenia is a rare ocular finding reported for the first time. Anemia is characterized by hemorrhages in all layers of retina, Roth spots, exudates, retinal edema, and venous dilatation. The differential diagnosis of such a presentation can be drug induced anemia, trauma, welding arc exposure, postcorneal or refractive surgery, e.g., LASIK, blood dyscrasias including autoimmune hemolytic anemia, thrombocytopenia, vasculitides, hypertension, diabetes mellitus, and dengue fever.
| Case Report|| |
A 17-year-old female with no history of any prior ocular complaints presented with sudden bilateral painless diminished vision for 45 days. There was no history of fever, vomiting, any head or ocular trauma. There was no history of any systematic afflictions such as diabetes, hypertension, any vasculitis, blood dyscrasias, blood transfusions, and any ocular surgical intervention or drug intake.
On general examination, the patient was calm, cooperative, and conscious. Severe pallor was present.
Vitals: Afebrile, blood pressure - 110/70 mmHg, pulse - 99/min.
Visual acuity: 6/60 OD and 6/36 OS. No improvement with pinhole.
Papillary responses and intraocular pressure were normal.
Anterior segment: Conjunctival pallor present.
Fundus examination showed subinternal limiting membrane macular hemorrhages in the right eye [Figure 1] and left eye [Figure 2].
Optical coherence tomography showed bilateral subinternal limiting membrane macular hemorrhage.
Hemogram: Hemoglobin (Hb) - 4.9 g%
Red blood cell count: 1.6 million/cmm
White blood cell count: 4000/cmm.
Neutrophil - 49%
Eosinophils - 3%
Basophils - 0%
Lymphocytes - 42%
Monocytes - 6%.
Packed cell volume - 14 vol%
Mean corpuscular volume - 87.5 cmm
Mean corpuscular Hb (MCH) - 30.6 pg
MCH concentration - 35.0%
Reticulocyte count - 0.1%
Platelet count - 1.41 lakh/cumm
Clotting time - 5 min 40 s
Bleeding time - 2 min 10 s
Serum B12-31 pg/ml (normal range: 180–914 pg/ml)
Folic acid - 3.94 ng/ml (normal: >6.59 ng/ml)
HIV screening test (tri-dot method): Nonreactive
Plasmodium vivax and Plasmodium falciparum: Negative.
VDRL test: Nonreactive
Lipid profile: Normal
Chest X-ray: Normal
Ultrasound abdomen: Normal
Peripheral smear: Macrocytic anemia.
The patient received one unit of blood transfusion and Vitamin B12 and folate supplements. Two weeks after blood transfusion, her best corrected visual acuity improved to 6/9 in the right eye and 6/6 in the left eye and her Hb is 7.9 g%.
Two weeks after treatment, fundus showed resolution of subinternal limiting membrane macular hemorrhages in the right eye [Figure 3] and left eye [Figure 4].
|Figure 3: Fundus picture of the right eye showing resolution of hemorrhage after treatment|
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|Figure 4: Fundus picture of the left eye showing resolution of hemorrhage after treatmentthrombocytopenia|
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| Discussion|| |
Anemia has been reported as an important risk factor for developing retinopathy in many case series, with a prevalence of 20–28.3%. The retinopathy was described due to several types of anemia such as iron deficiency anemia, aplastic anemia, sickle cell anemia, beta-thalassemia, pernicious anemia, and drug-induced anemia.,,,,, We diagnosed megaloblastic anemia as a cause of bilateral subinternal limiting membrane hemorrhage.
The manifestations of anemic retinopathy are nonspecific and may closely simulate hypertensive or diabetic retina. Retinal changes in anemia are cotton wool spots, venous tortuosity, and hemorrhages which may be present at all levels of the retina and choroid. All retinal hemorrhages can occur when Hb falls below 8 g/100 ml or if the platelet count falls below 50,000/cumm. The combination of severe anemia and thrombocytopenia is likely to produce retinal hemorrhages in a majority of patients., Factors such as anoxia, venous stasis, angiospasm, increased capillary permeability, and thrombocytopenia have been implicated in the pathogenesis of anemic retinopathy.
| Conclusion|| |
This rare case documented for the first time with bilateral subinternal limiting membrane macular hemorrhage with megaloblastic anemia without thrombocytopenia and other retinal features of anemic retinopathy. These hemorrhages regressed following treatment of megaloblastic anemia.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]