Bilateral macular hemorrhage due to megaloblastic anemia: A rare case report.

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.

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 [Fig. 1] and left eye [Fig. 2].

Figure 1

Fundus picture of the right eye showing macular hemorrhage

Figure 2

Fundus picture of the left eye showing macular hemorrhage

Optical coherence tomography showed bilateral subinternal limiting membrane macular hemorrhage.

Other investigations:

Hemogram: Hemoglobin (Hb) - 4.9 g%

Red blood cell count: 1.6 million/cmm

White blood cell count: 4000/cmm.

Differential count:

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.

Treatment

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 [Fig. 3] and left eye [Fig. 4].

Figure 3

Fundus picture of the right eye showing resolution of hemorrhage after treatment

Figure 4

Fundus picture of the left eye showing resolution of hemorrhage after treatment

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.[123456] 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.[7] 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.[89] 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.