Bilateral macular haemorrhages secondary to hepatitis-associated aplastic anaemia, treated with Nd:YAG laser posterior hyaloidotomy

Abstract

Hepatitis-associated aplastic anaemia (HAAA) is an uncommon but distinct variant of aplastic anaemia in which pancytopenia and bone marrow failure appears 2-3 months after an acute attack of hepatitis. Although bilateral vision loss may rarely be the initial presentation of aplastic anaemia, no such report is known in HAAA. Here the authors report such a case presenting with large premacular subhyaloid haemorrhages secondary to severe anaemia and thrombocytopenia. Anaemic hypoxic damage to the vessel wall together with increased cardiac output and low platelet counts are interacting causal factors in the development of bleeding. Though these haemorrhages are benign and usually improve spontaneously, the presence of blood may cause permanent macular changes before it resolves. Posterior hyaloidotomy enabled rapid resolution of premacular subhyaloid haemorrhage thereby restoring vision and preventing need for vitreo-retinal surgery. These patients should be advised to refrain from valsalva manoeuvres, ocular rubbing and vigorous exercise to prevent ocular morbidity.

Aplastic anemia presenting with bilateral, symmetric preretinal macular hemorrhages

“…Although premacular subhyaloid hemorrhages have been treated with drainage into the vitreous cavity via Nd:YAG laser, 5 this patient was observed closely, and his vision improved markedly due to reabsorption of the hemorrhages and an increase in platelet count during a 3-month period. Our case demonstrates that bilateral preretinal hemorrhages can be a presenting manifestation of aplastic anemia and that an ophthalmic examination can be of vital importance in the prompt diagnosis of this life-threatening disease.…”

Bilateral preretinal hemorrhage associated with Kikuchi-Fujimoto disease

“…Although bilateral preretinal hemorrhage has not been reported in KFD, it has been reported in autoimmune hemolytic anemia, 33 Dengue fever, 34 kala-azar, 35 Terson syndrome, 36 , 37 laser in situ keratomileusis (LASIK), 38 aplastic anemia 39 (due to various etiologies, including seronegative hepatitis, 40 chemotherapy and immunosuppressive drugs), 37 , 41 , 42 valsalva retinopathy (usually unilaterally and associated with trauma or exertion, which our patient did not have), 43 shaken baby syndrome, and other forms of child abuse. 44 Our patient's laboratory tests, medical history, and clinical presentations ruled out these potential diagnoses as well as infectious retinitis.…”

You are what you eat: ophthalmological manifestations of severe B12deficiency

“…Refractory cases of preretinal haemorrhages may require Nd:YAG laser posterior hyaloidotomy 10. Nd:YAG laser hyaloidotomy is an inexpensive, effective and apparently safe procedure for premacular subhyaloid haemorrhage, allowing rapid restoration of visual function and avoiding more invasive procedures 11–13.…”