Pre-macular hemorrhage in chronic malaria.

Sir/Madam,

Malaria is a common infectious disease in developing nations but rarely a cause of concern for ophthalmologists. We had such a unique case when a 28-year-old female presented with history of sudden onset painless blurred vision since 1 month in the right eye (RE) with mild spontaneous improvement since last 10 days. She was diagnosed chronic malaria with anemia 1 month back by a physician following complains of persistent fever and malaise. Peripheral blood film examination had confirmed the presence of parasites and hemolysis with hemoglobin recorded as 7.4 g/dl. Fever had subsided following a short course of chloroquine.

On examination best-corrected visual acuity (BCVA) was 6/18 and 6/6 in the right and left eyes, respectively. Both the eyes had normal anterior segment and IOP. Fundus examination of RE revealed resolving pre-macular hemorrhage overlying the fovea with hazy borders [Figure 1a]. LE fundus was normal. High Definition Ocular Coherence Tomography (HDOCT) images (Cirrus; Zeiss Meditec Inc, Dublin, CA) of the right eye revealed a dense pre-foveal opacity with corresponding optical shadow [Figure 1b]. Fluorescein angiography appeared to be normal in both the eyes as the lesion was present in the foveal avascular zone and no vascular anomaly was detected. She was advised regular follow-up and 15 days later RE BCVA had improved to 6/9p. The hemorrhage had decreased in size and become more defined [Figure 2a and b].

Figure 1

(a) Fundus photograph of RE showing resolving pre-macular hemorrhage. (b) HDOCT line scan of RE macula revealing a dense pre-macular lesion with corresponding optical shadowing

Figure 2

(a) Fundus photograph of RE showing decreased size of the pre-macular hemorrhage. (b) HDOCT line scan of RE showing decreased size of the pre-macular hemorrhage and the optical shadow

Anterior ischemic optic neuropathy,[1] retrobulbar neuritis[2] and sub-macular bleed[3] have been reported as a cause of vision loss with non-cerebral malaria. Anti-malarial drugs are also well-identified cause of retinopathy. Retinal hemorrhages can occur in cerebral malaria and have been identified as prognostic factors where they were commonly associated with vascular events.[4] Our patient was not a case of cerebral malaria and vision loss occurred before initiation of the antimalarial regimne which was given for a very brief period, ruling out drug toxicity. A possible cause could be localized vascular obstruction in the retinal venous system similar to the previously reported choroidal vascular anomaly,[3] though this could not be proved on angiography. Another likely explanation is anemic retinopathy induced by anemia of chronic malaria, which is well known to cause retinal vascular anomalies and pre-retinal hemorrhages.[5] This is consistent with the course and the site of the bleed in our patient. Such cases can hence be followed up without intervention.

To the best of our knowledge, this is the first documented case of pre-macular hemorrhage in malaria, possibly related to anemic retinopathy.