Spontaneous bilateral peripapillary, subhyaloid and vitreous hemorrhage with severe anemia secondary to idiopathic thrombocytopenic purpura

Abstract

A 42-year-old female presented to us with a complaint of sudden painless loss of vision in both eyes of three days duration. Visual acuity was 20/100 for distance in both eyes. Fundus examination showed bilateral peripapillary hemorrhages, with subhyaloid and vitreous hemorrhage in both eyes. Hematological investigations revealed hemoglobin (HB 7 gm %) and severe thrombocytopenia (12,000/ ul). She was referred to a hematologist where a diagnosis of idiopathic thrombocytopenic purpura (ITP) was made. She was treated for systemic condition with regular ophthalmic follow-up. Over the next nine months, retinal hemorrhages completely resolved and the patient regained her visual acuity. The purpose of this case report is to highlight the clinical presentation of severe anemia, which is different from previous reports and the role of an ophthalmologist in first detecting the Idiopathic thrombocytopenic purpura (ITP), which led to successful recovery.

Spontaneous bilateral peripapillary, subhyaloid and vitreous hemorrhage with only minor platelet deficit in idiopathic thrombocytopenic purpura

“…It has been reported by Rubenstein et al that there is a high incidence of retinal hemorrhage in patients with severe anemia (<80 g/L) and severe thrombocytopenia (<50×10 9 /L), but a much lower frequency in anemic patients without thrombocytopenia 10. However, this is not what we had observed from this patient, who had only mild thrombocytopenia (120×10 9 /L) and moderate anemia (93 g/L) when she presented with ocular symptoms, in contrast to severe thrombocytopenia in other case reports (12×10 9 /L by Majji et al; 42×10 9 /L by Pathengay et al; and <2×10 9 /L by Okuda et al) 7–9. Carraro et al demonstrated that retinopathy was closely associated with the conditions of severe anemia and severe, or very severe, thrombocytopenia 11…”

“…Her condition improved progressively, after she started on medical treatment. Similar findings were seen in Majji et al’s patient, in whom complete resolution of hemorrhages was noted after the patient had been managed through only systemic factors, without any invasive procedure 7. Nevertheless, vitrectomy can be beneficial for massive vitreoretinal hemorrhages 8.…”

“…There are no large case series on the spectrum of findings on ITP in eyes; mostly, these are single-case reports. Ophthalmic manifestations associated with ITP reported include vitreous hemorrhage,4 subconjunctival hemorrhage,5 massive subretinal hemorrhage with life-threatening intracranial hemorrhage,6 and vitreoretinal hemorrhages 7–9…”

Bilateral vitreous hemorrhage in children: Clinical features and outcomes

“…The most common cause of bilateral vitreous hemorrhage in the Western literature appears to be non-accidental trauma or the battered baby syndrome[ 2 ] followed by anecdotal reports of various ocular and systemic conditions such as vasculitis[ 1 ] or low platelet levels. [ 17 18 ] This stands in contrast to our series wherein firecracker injuries emerged as the most common cause. Vitreous hemorrhage secondary to firecracker injuries has been reported earlier.…”

Idiopathic thrombocytopenic purpura and its fundus features in a patient with diabetes mellitus

“…ITP is a relatively uncommon autoimmune haematologic condition, wherein platelets are destroyed leading to thrombocytopenia. Ophthalmic involvement in ITP is rare and mostly limited to subconjunctival hemorrhage,[ 1 ] preretinal, intraretinal, subretinal and/or vitreous hemorrhage,[ 2 3 4 5 6 ] which may be associated with intracranial bleeding in a Terson type phenomenon,[ 7 ] hemorrhage within the optic tract[ 8 ] and non-arteritic anterior ischaemic optic neuropathy. [ 9 ]…”