Dietary folate deficiency and bilateral retinal haemorrhages

Abstract

A 33-year-old man presented to the ophthalmology department with sudden onset of blurred vision in both eyes. He described symptoms of lethargy and had had recurrent aphthous ulcers. Fundoscopy showed multiple bilateral retinal haemorrhages (fi gure). Visual acuity was 18/6 in both eyes. Laboratory blood test results showed haemoglobin 48 g/L, mean cell volume 119 fL, white cell count 6·12×10/L, and platelets 86×10/L. Red cell folate was reduced at 103 μg/L (normal range 200–800 μg/L) and vitamin B12 was reduced at 178 ng/L (range 210–1000 ng/L). Replacement therapy with folic acid and hydroxo cobalamin resulted in rapid recovery of blood indices. Retinal appearances and visual acuity returned to normal over the next few months. Tissue trans glutaminase anti bodies, intrinsic factor antibodies, and part 1 Schilling test were normal. The patient admitted to an extremely poor diet with minimum intake of fruit or vegetables for some years. The severe macrocytic anaemia and retinal haemorrhages seemed to be a consequence of folate defi ciency solely as a result of poor dietary habit. Retinal haemorrhage is a well recognised complication of the hyperdynamic retinal circulation and tissue hypoxia induced by severe anaemia. Lancet 2006; 368: 2155