A 26yr old male was referred from the medical ward for an ophthalmology opinion for a sudden decrease of vision in both eyes for the past 2 days. He was already undergoing treatment in the medical ward for idiopathic thrombocytopenic purpura. The patient was apparently normal before 3 days and he was not taking any drugs for other illnesses. Routine blood investigations revealed thrombocytopenia and anemia for which multiple blood and platelet transfusions were done. On examination in the ophthalmology department, his visual acuity was counting fingers close to the face in both eyes. Intraocular pressures were normal in both eyes. The anterior segment in both eyes was normal, pupils were 3mm, equal, round, regular, and reacting to light briskly. Dilated fundus examination revealed multiple superficial and deep retinal hemorrhages and Roth spots in the posterior pole and large pre-retinal sub hyaloid hemorrhage over the macula in both eyes which explained the loss of vision. There were no vessel abnormalities or exudates to suggest diabetic or hypertensive retinopathy. Also, his blood pressure and blood glucose levels were within normal limits. Hence a diagnosis of thrombocytopenia associated retinopathy was made and he was referred for Nd: Yag laser hyaloidotomy to clear the hemorrhage over the macula. The patient was lost for follow-up. Ophthalmic manifestations of thrombocytopenia are rarely encountered, and thrombocytopenia manifesting with decreased visual acuity secondary to retinal hemorrhage has been previously reported only in very few cases. Idiopathic thrombocytopenic purpura can rarely result in significant morbidity or even mortality from bleeding complications. Other ophthalmic manifestations associated with thrombocytopenia include vitreous hemorrhage associated with intracranial bleeding in a Terson type phenomenon, hemorrhage within the optic tract, nonarteritic anterior ischemic optic neuropathy, and subconjunctival hemorrhage. Thrombocytopenia alone, even severe (a platelet count <50 000), is rarely sufficient to cause significant retinal hemorrhage. However, thrombocytopenia combined with anemia is a known risk factor, and retinal hemorrhages in association with thrombocytopenia have only been reported to occur with concurrent anemia.
Retinal hemorrhages are often an indication of an underlying blood dyscrasia, and their presence, in the absence of a known etiology, warrants evaluation. In addition to the ophthalmic examination, a thorough medical history, review of systems, and physical assessment of the skin and mucosal surfaces may aid the physician in assessing the urgency of hematologic evaluation. Patients exhibiting significant abnormalities may warrant urgent evaluation to initiate potentially life-saving interventions.
