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

Dear Editor,

We read with great interest the article titled “Spontaneous bilateral peripapillary, subhyaloid and vitreous hemorrhage with severe anemia secondary to idiopathic thrombocytopenic purpura” by Majji et al.[1]

We would like to share our experience in a similar case. The patient, a 56-year-old male was a known case of diabetes, hypertension and presented to us with blurring of vision in both eyes since 10 days. On examination, his best corrected visual acuity (BCVA) was 20/30, N8 in the right eye and 20/50,N12 in the left eye. Anterior segment examination was normal except for nuclear sclerosis Grade 1. Fundus examination of both eyes revealed intraretinal dot and blot hemorrhages suggestive of non-proliferative diabetic retinopathy, but could not account for the presence of subhyaloid hemorrhage and subretinal hemorrhage without any clinical evidence of neovascularization [Figs 1 and 2]. Fundus fluorescein angiogram (FFA) confirmed absence of neovascularization. Patient was examined by a hematologist for systemic evaluation and underwent routine blood counts, peripheral blood smear examination and bone marrow aspiration biopsy. His platelet count was 42,000/cmm, hemoglobin (Hb) level was 10.8 g% and bone marrow aspiration study revealed normocytic, normochromic anemia with plenty of megakaryocytes suggestive of platelet deficiency. He was diagnosed to have normocytic, normochromic anemia with idiopathic thrombocytopenic purpura (ITP). He received platelet transfusion followed by oral steroids. After one month, his platelet count increased to 2.15 lakh/cmm and was accompanied by resolution of retinal hemorrhages to a great extent. At final follow-up (three months after first presentation), BCVA improved to 20/20, N6 and 20/40, N10 in the right and left eye respectively, with platelet count of 2.5 lakh/cmm and fundus examination revealed marked resolution of hemorrhages [Figs 3 and 4].

Figure 1

Fundus photo of right eye showing pre retinal and subretinal hemorrhages before treatment of ITP

Figure 2

Fundus photo of left eye showing pre retinal and subretinal hemorrhages before treatment of ITP

Figure 3

Fundus photo of right eye showing marked resolution of hemorrhages after treatment of ITP

Figure 4

Fundus photo of left eye showing marked resolution of hemorrhage after treatment of ITP

ITP is known to cause vitreo-retinal and subretinal hemorrhages.[2-4] Retinal hemorrhages could be the first clinical manifestation as noted in our patient.[1] Oral corticosteroids and platelet transfusion administered in the initial management of ITP help in the resolution of vitreo-retinal hemorrhages as noted in our patient.[4] Though it is not uncommon to find retinal and / or subretinal hemorrhages in patients with ITP, FFA would be an important diagnostic tool in a patient with ITP and coincidental diabetic retinopathy to ascertain the cause of retinal hemorrhages.