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CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 94-96

Blurry vision unraveling underlying aplastic anemia


Department of Ophthalmology, IMS and SUM Hospital, Bhubaneswar, Odisha, India

Date of Submission25-Jun-2021
Date of Acceptance04-Mar-2022
Date of Web Publication23-May-2022

Correspondence Address:
Dr. Jasmita Satapathy
Department of Ophthalmology, IMS and SUM Hospital, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_85_21

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  Abstract 


A 23-year-old male presented with sudden diminution of vision in both eyes due to massive retinal hemorrhages involving the macula. Hematological workup revealed severe anemia with thrombocytopenia and leukopenia. A bone marrow biopsy was advised, and the diagnosis of Aplastic anemia was confirmed. Replacement therapy resulted in dramatic resolution of the fundus picture with improvement in visual acuity to near normal on follow-up visit after three months. A careful examination including dilated fundoscopy, a high index of suspicion, and prompt management can save vision as well as life in such cases.

Keywords: Anemic retinopathy, aplastic anemia, funduscopy, subfoveal hemorrhage


How to cite this article:
Satapathy J, Panigrahi PK, Thareja J. Blurry vision unraveling underlying aplastic anemia. J NTR Univ Health Sci 2022;11:94-6

How to cite this URL:
Satapathy J, Panigrahi PK, Thareja J. Blurry vision unraveling underlying aplastic anemia. J NTR Univ Health Sci [serial online] 2022 [cited 2022 Jun 26];11:94-6. Available from: https://www.jdrntruhs.org/text.asp?2022/11/1/94/345810




  Introduction Top


Aplastic anemia (AA) is a rare blood disorder characterized by pancytopenia with hypocellular bone marrow in the absence of an abnormal infiltrate or marrow fibrosis.[1] Its prevalence is relatively higher in the Asian population when compared to the United States and Europe.[2] Male preponderance is reported in many studies.[3],[4] Majority of the cases are idiopathic. At times AA can be life-threatening. Most patients die due to recurrent infection and severe spontaneous bleeding.[5] However, it is rare that the patient presents with sudden diminution of vision as the first complaint.

We report a case of bilateral retinal hemorrhages in a patient with no prior history of AA or other hematological disorders.


  Case Report Top


A 23-year-old male presented to the department of Ophthalmology complaining of sudden diminution of vision in both eyes since last six days, right eye being affected more than the left eye. General examination revealed a thin body built and significant pallor. His best-corrected visual acuity (BCVA) was 6/60 in the right eye and 6/24 in the left eye. Intraocular pressure and anterior segment of both eyes were within normal limits. On dilated fundus examination, both eyes showed massive pre-retinal, intra-retinal, sub-retinal, and sub-foveal hemorrhages, Roth spots, and internal limiting membrane folds [Figure 1]a and [Figure 1]b. On further investigation, his hemoglobin (Hb) was found to be 4.1 gm/dL, total platelet count (TPC) was 2000/ul, total leukocyte count (TLC) was 690/ul. A provisional diagnosis of blood dyscrasia was made, and the patient was referred to the department of Hematology for further evaluation. He was advised a bone marrow biopsy, which revealed pancytopenia with hypocellular marrow. A diagnosis of aplastic anemia with anemic retinopathy in both eyes was made. The patient was treated with three units of packed red blood cells and 15 units of random donor platelets. One month after treatment, his BCVA improved to 6/18 in the right eye and 6/6 in the left eye. On fundus examination, there was a significant reduction in the size and number of retinal hemorrhages [Figure 2]a and [Figure 2]b. On three months follow-up, complete resolution of retinal hemorrhages could be noticed with near-normal visual acuity in both the eyes [Figure 3]a and [Figure 3]b.
Figure 1: Color fundus photograph of (a) right eye and (b) left eye, showing preretinal, intraretinal, and subfoveal hemorrhages, Roth spots, and folds in the internal limiting membrane

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Figure 2: Color fundus photograph of (a) right eye and (b) left eye, at one month follow-up

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Figure 3: Color fundus photograph of (a) right eye and (b) left eye, at three months follow-up

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  Discussion Top


Various ophthalmic manifestations reported in AA include retinal hemorrhage, vitreous hemorrhage, cotton wool spots, central retinal venous occlusion like picture, optic disc edema, macular edema, peripheral retinal vasculopathy, lid hematoma, subconjunctival hemorrhage, and orbital hemorrhage.[5],[6],[7] The prevalence of retinopathy in AA varied from 20–28.3% in earlier studies.[5] The turbulence of blood, endothelial injury, and bleeding diathesis have been implicated in the occurrence of bleeding in such cases.[5] The risk of retinal hemorrhage increases when the Hb level is below 8 gm/dL.[8] The prognosis of retinal hemorrhages is good when treated early with replacement therapy.[5] However, it remains undetected as long as visual acuity is normal. Our patient presented early, as he developed bilateral diminution of vision. Visual loss in our case was due to a subfoveal hemorrhage. Such severe presentations are important to be known to avoid permanent visual loss and life-threatening complications.


  Conclusion Top


The eye acts as a window to the body. It gives direct access to much of the internal working of the body, especially arteries. Examination of the retina often provides clues that warn of some health issues elsewhere in the body. This case highlights the importance of detailed ocular examination in all patients presenting to an eye clinic. Moreover, the diagnosis of retinal hemorrhage due to aplastic anemia should be kept in mind in patients presenting with a sudden decrease in vision.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Clucas D, Fox LC, Wood EM, Hong FS, Gibson J, Bajel A, et al. Australian aplastic anaemia registry steering committee revisiting acquired aplastic anaemia: Current concepts in diagnosis and management. Intern Med J 2019;49:152-9.  Back to cited text no. 1
    
2.
Kojima S. Aplastic anemia in the orient. Int J Hematol 2002;76(Suppl 2):173-4.  Back to cited text no. 2
    
3.
Mahapatra M, Singh PK, Agarwal M, Prabhu M, Mishra P, Seth T, et al. Epidemiology, clinico-haematological profile and management of aplastic anaemia: AIIMS experience. J Assoc Physicians India 2015;63 (3 Suppl):30-5.  Back to cited text no. 3
    
4.
Issaragrisil S, Kaufman DW, Anderson T, Chansung K, Leaverton PE, Shapiro S, et al. The epidemiology of aplastic anemia in Thailand. Blood 2006;107:1299-307.  Back to cited text no. 4
    
5.
Mansour AM, Lee JW, Yahng SA, Kim KS, Shahin M, Hamerschlak N, et al. Ocular manifestations of idiopathic aplastic anemia: Retrospective study and literature review. Clin Ophthalmol 2014;8:777-87.  Back to cited text no. 5
    
6.
Mansour AM, Salti HI, Han DP, Khoury A, Friedman SM, Salem Z, et al. Ocular findings in aplastic anemia. Ophthalmologica 2000;214:399-402.  Back to cited text no. 6
    
7.
Lee AR, Bhullar PK, Fekrat S. Aplastic anemia presenting with bilateral, symmetric preretinal macular hemorrhages. Can J Ophthalmol 2016;51:e159-60.  Back to cited text no. 7
    
8.
Selvan H, Azad SV, Ramesh P, Bhakthaganesh K. Retinopathy in severe aplastic anaemia. BMJ Case Rep 2019;12:e232426.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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