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   Table of Contents      
PHOTO ESSAY
Year : 2018  |  Volume : 66  |  Issue : 9  |  Page : 1315-1317

Central retinal vein occlusion revealing celiac disease: The first report of two cases from India


1 Department of Vitreo-Retina, Dhami Eye Care Hospital, Ludhiana, Punjab, India
2 Department of Gastroenterology and Liver Diseases, SPS Hospital, Ludhiana, Punjab, India
3 Department of Cataract and Refractive Surgery, Dhami Eye Care Hospital, Ludhiana, Punjab, India

Date of Submission11-Mar-2018
Date of Acceptance06-May-2018
Date of Web Publication20-Aug-2018

Correspondence Address:
Dr. Ravinder Kaur Malhi
Department of Vitreo-Retina, Dhami Eye Care Hospital, 82-B Kitchlu Nagar, Ludhiana - 141 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_351_18

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  Abstract 


Keywords: Anemia, celiac disease, central retinal vein occlusion


How to cite this article:
Malhi RK, Dhami A, Malhi NS, Soni A, Dhami GS. Central retinal vein occlusion revealing celiac disease: The first report of two cases from India. Indian J Ophthalmol 2018;66:1315-7

How to cite this URL:
Malhi RK, Dhami A, Malhi NS, Soni A, Dhami GS. Central retinal vein occlusion revealing celiac disease: The first report of two cases from India. Indian J Ophthalmol [serial online] 2018 [cited 2019 Jun 16];66:1315-7. Available from: http://www.ijo.in/text.asp?2018/66/9/1315/239354




  Case Top


We report two cases of 35-year and 25-year-old females presented with visual acuity of 6/60 and 5/60 for the right and left eye on Snellen's chart. On evaluation, both eyes showed central retinal vein occlusion (CRVO) [Figure 1]a and [Figure 1]b, [Figure 2]a and [Figure 2]b. The fundus fluorescein angiography showed delayed venous filling and blocked fluorescence with no evidence of neovascularization [Figure 1]e and [Figure 2]c. The optical coherence tomography showed cystoid macular edema (CME) [Figure 1]f and [Figure 3]a. Investigations for Case 1 revealed marked iron deficiency anemia and thrombocytosis and for Case 2 showed moderate anemia [Table 1]. On physician evaluation, serum antitissue transglutaminase antibody titers were done due to suspicion of celiac disease (CD), which was highly positive. Upper gastrointestinal endoscopy showed scalloping of duodenal folds and loss of villi and thus duodenal biopsy was performed which showed signs of atrophic villi, decreased villous/crypt ratio (<1.1), and cryptic hyperplasia [Figure 4]a and [Figure 4]b graded as Modified Marsh Grade Type 3c,[1] confirming the diagnosis of CD. The patients were managed with gluten-free diet and iron and folate supplementation and each eye underwent intravitreal bevacizumab (1.25 mg/0.5 ml) for the management of CME which showed improvement in vision, resolution of hemorrhages [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e and [Figure 2]d,[Figure 2]e, [Figure 2]f, and CME [Figure 1]g, [Figure 3]b and [Figure 3]c over subsequent follow-ups.
Figure 1: (a and b) Posterior pole fundus photograph of right and left eye at initial presentation, (c and d) images of the right eye at subsequent follow-up at 2 monthly intervals after change of diet plan with regard to celiac disease and subsequent clearing of the retinal hemorrhages; (e) the mid arteriovenous phase of fundus fluorescein angiography shows blocked fluorescence due to hemorrhages; (f) the presence of cystoid macular edema at fovea, and (g) the resolution of cystoid macular edema postintravitreal injection of bevacizumab

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Figure 2: (a and b) Posterior pole fundus photograph of left and right eye at initial presentation, (c) the mid arteriovenous phase of fundus fluorescein angiography increased optic disc vascularity and increased early and late disc fluorescence with blocked fluorescence due to hemorrhages. (d-f) Images of the left eye at subsequent follow-up at 2 monthly intervals after change of diet plan with regard to celiac disease and subsequent clearing of the retinal hemorrhages

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Figure 3: (a) The presence of cystoid macular edema for the second case at initial presentation and (b and c) the subsequent decrease in cystoid macular edema after intravitreal bevacizumab injection

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Table 1: The details of investigation for both Case 1 and Case 2

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  Discussion Top


The classic triad of CD: diarrhea, abdominal pain, and malabsorption are seen only in 10%–20% of cases only.[2],[3] In India, most cases of CD are in the northern part of country, as wheat is the staple diet. CD patients have a lifelong risk to develop thrombosis. Reported mechanisms for retinal vein occlusion (RVO) include (a) lack of absorption of Vitamin K, deficiencies of protein C and S, antithrombin, Vitamin B12 and folate, (b) hyperhomocysteinemia, and (c) dehydration and hyperviscosity of blood due to malabsorption and chronic diarrhea.[1]


  Conclusion Top


We recommend inclusion of Anti-Ttg titers in young patients presenting with a RVO, as it is a highly sensitive (74%–94%) and specific test (97%–100%)[1] and can save the patient from life-threatening thrombotic complications.[2],[3],[4]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yachha SK, Poddar U. Celiac disease in India. Indian J Gastroenterol 2007;26:230-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Jomni T, Bellakhal S, Abouda M, Abdelaali I, Douggui H. An atypical presentation of celiac disease: Central retinal vein occlusion. Pan Afr Med J 2015;22:300.  Back to cited text no. 2
    
3.
Lee ES, Pulido JS. Nonischemic central retinal vein occlusion associated with celiac disease. Mayo Clin Proc 2005;80:157.  Back to cited text no. 3
    
4.
Martins TG, Costa AL, Oyamada MK, Schor P, Sipahi AM. Ophthalmologic manifestations of celiac disease. Int J Ophthalmol 2016;9:159-62.  Back to cited text no. 4
    


    Figures

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