Bilateral Retinal Hemorrhages Research Articles

Prolonged unexplained event might change an “unreliable perpetrator” into a “reliable resuscitator”

During the 1980′s a sudden life-lessness attack in a very young infant was described as “near-SIDS”, and a caregiver who observed and tried to revive the infant was considered to be reliable and honourable. If, after the later acceptance of the traditional shaken baby theory, bilateral thin subdural hemorrhages (SDH) and retinal hemorrhages (RH) are detected after a lifelessness attack such a reliable caregiver has by default been transformed into an unreliable perpetrator of violent shaking. In 2016, the term “near-SIDS” was – via “apparent life-threatening event” (ALTE) − replaced by “brief resolved unexplained event” (BRUE). We suggest that such a life-threatening event is not always brief, and not always resolved. Based on a neglected hypoxia theory from 2004 we suggest as a hypothesis that a prolonged episode of apnea can result in brain hypoxia, brain edema, SDH, RH and increased intracranial pressure. The new hypothesis includes two new concepts: Prolonged Non-fatal Unexplained Event (PNUE) and Prolonged Fatal Unexplained Event (PFUE) which together with the hypoxia theory might explain why these two separate diagnoses have been conflated into one, viz. shaken baby syndrome (SBS). We suggest a study design that might corroborate or falsify the hypothesis, and if our hypothesis is corroborated, current “unreliable perpetrators” could be re-established as reliable resuscitators.

Frosted Branch Angiitis Associated with COVID-19-related Multisystem Inflammatory Syndrome in Children

Purpose: To report a case of frosted branch angiitis associated with COVID-19-related multisystem inflammatory syndrome in children (MIS-C).Case summary: An 8-year-old boy was referred to the ophthalmology clinic with decreased visual acuity in his right eye. The initial best-corrected visual acuity (BCVA) was 20/63 in the right eye and 20/32 in the left eye. Upon fundus examination, bilateral frosted branch-like vascular sheathing and retinal hemorrhage were observed. Optical coherence tomography (OCT) demonstrated macular edema. Fluorescein angiography revealed late staining and leakage of affected retinal vessels. The patient exhibited persistent fever, rash, and gastrointestinal symptoms, accompanied by an increase in inflammatory markers in laboratory tests. Testing for SARS-CoV-2 immunoglobulin G (IgG) was positive, although there was no evidence of any other autoimmune diseases or viral infections. The patient was diagnosed with frosted branch angiitis associated with MIS-C. Treatment included systemic steroids and 1% prednisolone eye drops. After 2 weeks, the BCVA improved to 20/20 in both eyes, and all clinical signs resolved without recurrence.Conclusions: In patients with frosted branch angiitis without any other apparent cause, the possibility of MIS-C should be considered. Testing for COVID-19 infection is recommended.

Retinal haemorrhage after cardiopulmonary resuscitation of a patient

Aims/Purpose: We present a rare case of a patient who presented with bilateral retinal haemorrhage after cardiopulmonary resuscitation (CPR).Methods: A 37‐year‐old man, with a medical history of allergic bronchial asthma and a BMI >35, was referred to our emergency department from the cardiology clinic. He complained of sudden, painless, monocular visual acuity reduction after cardiac arrest and CPR because of an acute myocardial infarction (right coronary). He underwent a complete ophthalmic examination, as well as multimodal imaging and he was under close monitoring for the following months.Results: In his initial ophthalmic examination, best corrected visual acuity was 0.1 in his right eye and 1.0 in his left eye (Snellen's chart). Intraocular pressure was 14 mmHg and 15 mmHg in his right and left eye, respectively. Dilated fundus examination showed bilaterally scattered sub‐retinal, intraretinal and pre‐retinal haemorrhages in the posterior pole, with involvement of the right fovea. After the resolution of the haemorrhages, a fluoroangiography was performed which revealed delayed central retinal vein filling in the right eye. 2 months later, during follow‐up examination, visual acuity in the right eye was 0.7 and in the left eye 1.0. The haemorrhages have been absorbed bilaterally, leaving in the right eye a sub‐foveal photoreceptor and RPE disruption.Conclusions: Retinal haemorrhages can be observed after CPR. According to the literature, there have been reports of retinal haemorrhages in infants after CPR. Meanwhile, there is only one published case of an adult with associated comorbidities with this clinical presentation. The underlying pathophysiology of this clinical entity is still unclear, although a potential relationship between the increase in central venous pressure during CPR, and sequential retinal venous stasis is suspected.

Bilateral Retinal Haemorrhages as Primary Ocular Manifestation of Chronic Myeloid Leukaemia - A Case Report

Chronic myeloid leukaemia (CML) in a patient with pre.existing uncontrolled diabetes and hypertension is rarely encountered but must be detected early for appropriate management with systemic chemotherapy. Significant fundus finding mimic diabetic and hypertensive retinopathy, which makes the diagnosis of CML challenging. Early recognition and treatment of the underlying condition can prevent further vision loss and overall morbidity and mortality. Here, we report a case of bilateral retinal haemorrhages as one of the manifestations of CML.

Improvement in visual acuity and retinal phenotype with intravitreal aflibercept (anti-VEGF) in POEMS syndrome with Castleman disease variant

A woman in her thirties with no ophthalmic history presented two days of flashes and floaters. She had reduced right-eye visual acuity, bilateral retinal hemorrhages, and papilledema. She was diagnosed with polyneuropathy, organomegaly, endocrinopathy, myeloma protein, and skin changes (POEMS) syndrome with Castleman disease variant, with elevated systemic levels of vascular endothelial growth factor (VEGF). Three doses of aflibercept (VEGF blocker) were administered to the right eye. The right eye improved from 6/60 to 6/5 after treatment. We suggest that intravitreal VEGF blockade should be considered to preserve vision in patients with POEMS syndrome and high circulating VEGF.

A rare case report of scleral necrosis in a patient with aplastic anemia

A 15-year-old male presented with swelling and redness in the right eye of 1-month duration. The patient was a known case of aplastic anemia. Clinical examination revealed bilateral retinal hemorrhages and scleral necrosis in the right eye. The patient was treated with topical fortified Vancomycin and lubricating eye drops and received blood transfusion. There was an improvement in ocular condition following the initiation of therapy. Scleral necrosis is a rare but potentially blinding complication in patients with aplastic anemia. Ophthalmologists should be aware of this complication and follow-up such patients closely.

Central Pontine Myelinolysis in a Patient with Hepatosplenic T Cell Lymphoma and Hemophagocytic Lymphohistiocytosis (P6-4.007)

<h3>Objective:</h3> To discuss a rare case of central pontine myelinolysis (CPM) in a patient with hepatosplenic T cell lymphoma (HSTL) and hemophagocytic lymphohistiocytosis (HLH). <h3>Background:</h3> HSTL is a rare disease characterized by infiltration of mature T cells within the sinusoids of the spleen, liver, and bone marrow. Hyponatremia prior to orthotopic liver transplant for liver failure has previously been identified as a risk factor for the development of CPM due to possible disruption of astrocyte metabolism and impaired capacity to regulate osmotic changes leading to secondary dysfunction of the blood brain barrier. CPM has also previously been discovered in EBV positive HLH. <h3>Design/Methods:</h3> We conducted a case report and literature review with PubMed search terms: 1) “central pontine myelinolysis,” “hyponatremia,” and “liver” 2) “central pontine myelinolysis,” “hemophagocytic lymphohistiocytosis,” and “hemophagocytic syndrome” 3) “central pontine myelinolysis” and “hepatosplenic T cell lymphoma.” <h3>Results:</h3> A 20-year-old EBV negative male presented with fever, splenomegaly, and blurry vision with bilateral retinal hemorrhages. Workup was significant for pancytopenia, mild hypovolemic hyponatremia secondary to emesis (initially 132 mmol/L), triglycerides 377, INR 1.2, ALT 55, and ALP 402. HSTL and HLH were confirmed on bone marrow biopsy. He was found to have subclinical CPM on MRI brain without contrast which resolved on 2 month follow-up imaging after 3 rounds of ifosfamide, carboplatin, and etoposide (ICE) intrathecal chemotherapy. We found no prior literature describing HSTL and CPM, 22 articles regarding CPM and liver transplant, and 1 article describing CPM and HLH. <h3>Conclusions:</h3> CPM should be considered as a neurologic complication in patients with HSTL and HLH. We report such a case, despite only mild levels of hyponatremia, the absence of liver failure, and negative EBV status. Future research should explore the connection between these factors to further our understanding of osmotic regulation of the blood brain barrier leading to CPM. <b>Disclosure:</b> Dr. Avila has nothing to disclose. Mr. AW has nothing to disclose. Dr. Danziger has nothing to disclose. Dr. Kim has nothing to disclose. Dr. Tan has nothing to disclose. Dr. Schlick has nothing to disclose.

Acquired Factor VII Deficiency Associated With Chronic Myeloid Leukemia Blast Crisis.

Factor VII (FVII) is an important, vitamin K-dependent clotting factor. Acquired FVII deficiency is a rare entity that is associated with serious bleeding complications. We report a case of acquired FVII deficiency in a patient with recurrent chronic myeloid leukemia in blast crisis who developed bilateral retinal hemorrhages. The coagulopathy was corrected with the initiation of chemotherapy and subsequent reduction in peripheral blast count.

Successful Desensitization of Severe Alloimmune Platelet Refractoriness and Provision of Permissive Platelet Transfusions with a Novel IgG-Targeted Enzyme Therapeutic

AK and JCS contributed equallyBACKGROUND Alloimmune platelet refractoriness (APR), inadequate response to platelet transfusion secondary to alloantibodies targeting Human Leukocyte Antigens (HLA), affects ~25% of acute myeloid leukemia (AML) patients. For profoundly sensitized thrombocytopenic patients, HLA- or crossmatch-compatible platelet units may be unavailable, increasing the risk of thrombocytopenic hemorrhage. Imlifidase cleaves systemic IgG precluding complement fixation/phagocytosis and has been used to desensitize renal allograft recipients.1 Here we show that desensitization with imlifidase can significantly improve compatible platelet availability in APR and post-hematopoietic stem cell transplant platelet nadir. PATIENT CASE A 43-year-old woman with AML treated with cytarabine and daunorubicin was referred for matched-unrelated donor allogeneic hematopoietic progenitor cell transplantation. Her induction, at an outside institution, was complicated by bilateral retinal and mucosal hemorrhage secondary to APR and profound thrombocytopenia (platelet count to 0/µL). On presentation, her panel reactive antibody (PRA) showed exquisite sensitization (99.9%, i.e. ~99.9% of all donor platelet units predicted incompatible), precluding identification of HLA-compatible platelet units to support the patient through her anticipated platelet nadir. Desensitization included rituximab 375 mg/m2 (transplant D-13 and -6), therapeutic plasma exchange (TPE, D-2 and -1) and FDA-emergency-use-authorized imlifidase 0.25 mg/kg IV (D-1 and D+1). Following imlifidase administration, the number of unacceptable antigens and PRA decreased significantly (Figure) allowing sufficient compatible platelets to be identified and procured. During admission, the patient received 7 total platelet transfusions and experienced no hemorrhage (Table). She was discharged stable, post-platelet engraftment on D+19. STUDY DESIGN With IRB approval, the number of predicted clinically significant alloantibodies (antibodies with ≥ 3000 mean fluorescence intensity, MFI) and PRA (LABScreen single antigen and PRA Class I, One Lambda/ThermoFisher, West Hills, California) were compared at baseline, after rituximab/TPE, and after imlifidase administration. Corrected count increment (CCI) to platelet transfusions administered following imlifidase desensitization was calculated. CCI > 5000 was judged a permissive transfusion. Categorical variables were compared with Chi-squared followed by Fisher's Exact. P < .05 was significant. RESULTS AND CONCLUSION Compared to the baseline, unacceptable antigens (antigens targeted by antibodies at clinically significant levels) decreased significantly after rituximab/TPE (N=53/55 to 44/55 antigens, P = .015) and imlifidase (N = 44/55 to 16/55, P < .0001). PRA did not decrease significantly with rituximab/TPE (99.9 to 99.5%, P = .22) but did following imlifidase (99.5 to 87.2%, P < .0001). Of 7 transfusions given post imlifidase, the median CCI was 6000 (interquartile range: 500-7500), N=5/7 were judged permissive. In summary, the imlifidase-mediated decrease in PRA significantly aided the identification of numerous compatible platelet units for this patient and prevented further thrombocytopenic hemorrhage. Our limited data suggest a potentially novel application of imlifidase for desensitization of highly platelet allo-refractory patients requiring multiple platelet transfusions over a short period. We will perform western blot analysis of antibodies from in vivo samples collected over the treatment course to compare antibody fragmentation over time, as partially cleaved immunoglobulin detected by our microbead-based assays may not be pathologic.2 Additionally, as the patient's initial antibody levels exceeded the range of linearity of the bead-based assay, serial dilution studies of patient serum over the treatment course will more precisely semi-quantitate the true peak antibody levels. REFERENCES 1. Jordan SC, Legendre C, Desai NM, et al. Imlifidase desensitization in crossmatch-positive, highly sensitized kidney transplant recipients: results of an international phase 2 trial (Highdes). Transplantation. 2021;105(8):1808-1817. 2. Bockermann R, Järnum S, Runström A, et al. Imlifidase-generated single-cleaved IgG: implications for transplantation. Transplantation. 2022;106(7):1485-1496. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Prevalence, Characteristics, and Risk Factors of Retinal Hemorrhage among Full-Term Neonates in Southern China.

Neonatal retinal hemorrhage (RH) is the most common ocular fundus disease among newborns. Early detection and timely intervention are vital for reducing the risk of visual impairment caused by RH. However, little is known about the prevalence, characteristics, and risk factors of RH in southern China. Full-term infants born in Qingyuan City during the first 10 days of each month in 2021 were included in this study. All infants underwent RetCam III retinal examinations. Detailed information on retinal hemorrhage, including involved eyes, bleeding severity, and affected area (extrafoveal macula, fovea, or optic disc), and clinical information on the neonates and their mothers was collected. The results showed that among the 1072 eligible neonates, 266 (24.8%) had neonatal retinal hemorrhage. Consistent bilateral retinal hemorrhage severity was observed in 83.2% of the cases. The prevalence of optic disc involved RH, extrafoveal macular involved RH and foveal involved RH were 23.7%, 81.2% and 2.63%, respectively. Multivariate logistic regression analysis showed that lower birth weight (OR, 0.63; 95% CI, 0.40-0.99; p < 0.05) and vaginal delivery (OR, 20.6; 95% CI, 9.10-46.5; p < 0.001) were risk factors of neonatal RH. The area under the ROC curve of vaginal delivery, combined with birth weight, as predictors of neonatal RH was 0.73, with 85.3% sensitivity and 23.9% specificity. The birth weight cutoff was 3460 g. Our results suggested that neonatal RH is common in full-term neonates in southern China. It usually has the same severity in both eyes and mostly involves the extrafoveal macular region. Vaginal delivery and low birth weight are risk factors for neonatal RH.

Bilateral retinal hemorrhage after acute respiratory distress syndrome (ARDS) with COVID-19 pneumonia

Bilateral retinal hemorrhage after acute respiratory distress syndrome (ARDS) with COVID-19 pneumonia

An unusual association between pancreatic cancer and Purtscher-like retinopathy: Presentation of a unique case.

IntroductionPurtscher's retinopathy causes sudden loss of vision of varying severity, secondary to head injury or chest compression. Its pathophysiology is unclear. Purtscher's-like retinopathy has more attenuated clinical and objective features and can be associated with many non-neoplastic pathologies.Otherwise, an association of this kind of retinopathy with malignancies has been described once in the Literature. We present a case report on a unique association between pancreatic cancer and Purtscher-type retinopathy.Case presentationA 79-year-old man with reduced central vision in both eyes required an ophthalmic evaluation. Visual acuity was 20/40 in the right eye and 20/50 in the left eye. Fundus examination showed yellow-white peripapillary spots and bilateral retinal hemorrhages in the superficial retina.The patient complained of abdominal pain and received a CT scan of the abdomen, which showed a pancreatic mass extending into the spleen. A percutaneous needle biopsy sample showed mucinous pancreatic adenocarcinoma.Clinical discussionThis case report should warn of a possible association between pancreatic adenocarcinoma and Purtscher's-like retinopathy.ConclusionPatients with this kind of retinopathy should be evaluated to rule out not only benign associated disease, but also malignant tumors of the pancreas.

Насильницька травма голови в немовлят, або Синдром струшеної дитини: педіатричні аспекти

The article is devoted to the problem unfamiliar to medicians, lawyers and forensic doctors - «the shaken baby syndrome». Today this condition is called «violent head trauma». Violent head trauma in newborns is a variant of the child abuse syndrome and is associated with high mortality and impaired child development not only in early age, but also in later life, it affects the quality of life of children and their families. The social and psychological causes of violence against infants, the mechanisms of trauma received in the framework of the likelihood of child abuse are described. An integrated management according to the established degree of probability of child abuse is proposed. Particular attention is paid to modern diagnostic methods in the article. With violent head trauma in infants, as a rule, there are no signs of external trauma, and the clinical symptoms are characterized by wide variability. That is why the main diagnostic methods are neuroimaging (computed tomography, magnetic resonance imaging, neurosonography), x-ray examination of the skeleton, examination by an ophthalmologist. The diagnosis is established by the presence of classic symptoms of shaken infants: subdural and subarachnoid hemorrhages, bilateral retinal hemorrhage, diffuse brain damage. An assessment of the probability of violent head trauma as a cause of acute intracranial trauma in infants is presented. No conflict of interests was declared by the authors. Key words: violent head trauma, diagnosis, infants.

Acute myeloid leukemia onset with bilateral retinal hemorrhages

Acute myeloid leukemia onset with bilateral retinal hemorrhages

Multiple bilateral retinal hemorrhages: An unusual presentation of megaloblastic anemia

The purpose is to report the occurrence of bilateral retinal hemorrhages in megaloblastic anemia and its management. A 42-year-old male presented with sudden and painless diminution of vision in both eyes. The ophthalmologic evaluation revealed bilateral white-centered, sub-internal limiting membrane, blot- and flame-shaped hemorrhages near disc, and macula. Hematological evaluation revealed megaloblastic anemia with hemoglobin 6.6 g/dl with no thrombocytopenia. Posttreatment increase in hemoglobin was noted with resolution of retinal hemorrhages and normal foveal contour in both eyes. The careful and detailed ophthalmic evaluation of anemic patients is required for the early diagnosis and management of vision-related complications.

Reply to comments on bilateral retinal hemorrhages and macular edema in a patient with dengue fever associated with cerebral hemorrhage

Reply to comments on bilateral retinal hemorrhages and macular edema in a patient with dengue fever associated with cerebral hemorrhage

Birth-related retinal hemorrhages: The Soonchunhyang University Cheonan Hospital universal newborn eye screening (SUCH-NES) study.

To report the prevalence, related factors, and characteristics of birth-related retinal hemorrhages (RHs) according to their severity in healthy newborns using a telemedicine network and wide-field digital retinal imaging (WFDRI). Newborns who underwent WFDRI at 61 obstetrics/gynecology hospitals between January 2017 and December 2019 were enrolled. Demographics and related factors were compared among newborns with and without RHs. The newborns' eyes were divided into the minimal, mild, moderate, and severe groups according to the number of RHs, and characteristics like bilaterality, laterality, involved retinal layer, involved zone, macular and/or optic nerve (ON) involvement were compared. Among 56247 newborns, 13026 had birth-related RHs (23.2%). Normal spontaneous vaginal delivery (NSVD) showed the highest association with RHs (odds ratio, 19.774; 95% confidence interval, 18.277-21.393; P < 0.001) on multivariate analysis. Bilateral RHs (8414/13026; 64.59%) were more common than unilateral RHs (4612/13026; 35.41%); however, unilateral RHs (2383/4217; 56.51%) were more common than bilateral RHs (1834/4217; 43.49%) in the minimal group. RHs showed no laterality differences between the two eyes (P = 0.493). Most RHs were intraretinal (18678/21440; 87.12%), and 2328 (31.65%) eyes with preretinal hemorrhage were observed in the severe group. Zone I RHs were common in the minimal (7072/7090; 99.75%), mild (4953/4960; 99.86%), and moderate (2013/2035; 98.92%) groups; zone I and II RHs were common in the severe group (4843/7355; 65.85%); and RHs in zone III were rare (7/21440; 0.03%). Most RHs showed no macular and/or ON involvement in the minimal and mild group; however, this was common in the severe group (7111/7355; 96.68%). Birth-related RHs were common in healthy newborns and were significantly associated with NSVD. RHs were usually bilateral, intraretinal, and distributed posterior to the retina, but severe RHs had unique characteristics. Future long-term and longitudinal studies are required to elucidate the prognosis of severe RHs.

Retinal haemorrhage in infants investigated for suspected maltreatment is strongly correlated with intracranial pathology

To test the two prevailing hypotheses regarding the aetiology of infant retinal haemorrhage: (a) traction forces exerted by the lens and/or corpus vitreum on the retina during infant shaking or (b) retinal vessel leakage secondary to intracranial pathology and raised intracranial pressure. Comparison of medical findings and reported type of trauma in infants investigated for suspected physical abuse with presence (n=29) or non-presence of retinal haemorrhage (RH) (n=119). Intracranial pathology was recorded in 15 (13%) of the non-RH cases and in 27 (97%) of the RH cases (p<0.0001). All 18 infants with bilateral RH had intracranial pathology. Of 27 infants subjected to witnessed or admitted shaking, two were in the group with RH. One had a single unilateral RH and no intracranial pathology. The other had bilateral RH and intracranial pathology with non-specific white matter changes, acute subdural and subarachnoid haemorrhages, and suspected cortical venous thrombosis. In 15 RH cases, there was no trauma reported and no findings other than RH and intracranial pathology. Accidental blunt head trauma was reported in 7 RH cases. The present study indicates that RH in infants is secondary to intracranial pathology of non-specific aetiology.

Multimodal imaging of bilateral immunogammopathy maculopathy associated to Waldenström's macroglobulinemia.

Our aim is to report a case with bilateral Waldenström's macroglobulinemia (WM) associated maculopathy, assessed with multimodal imaging including swept source optical coherence tomography (SS-OCT) and OCT-Angiography (OCT-A). Observational case report. A 61-year-old diabetic woman with history of treated WM currently in remission, presented with progressive bilateral visual loss. Best-corrected visual acuity was 20/100 in the right eye (RE) and 20/200 in the left eye (LE). Fundus examination showed bilateral microaneurysms and retinal punctuate hemorrhages and a large macular serous detachment in the LE. There was no retinal ischemia on FA nor macular dye leakage. SS-OCT showed a significant schisis-like intraretinal fluid accumulation in the RE and a large prominent macular detachment with significant subretinal fluid accumulation in the LE. Retinal and choriocapillaris vascular densities were normal on OCT-A. Our case illustrated characteristic multimodal imaging findings in WM associated maculopathy such as schisis-like intraretinal fluid accumulation and angiographically silent serous macular detachment. OCT-A could non-invasively analyze macular vascular densities layer-by-layer, without noticing any vascular anomaly.

Hemorrhagic Eye Involvement in Acute Myeloid Leukemia

Purpose: Through an observation, we focus on the ocular hemorrhagic manifestations during AML and the role of the ophthalmologist in the management of this condition. Methods: We report the case of a 14-year-old boy whose hemorrhagic ocular involvement was indicative of an AML. Results: This patient with no known history was sent for an ophthalmology consultation for a sudden decline in bilateral visual acuity associated with a bilateral periorbital ecchymosis. The interrogation found an effort of vomiting preceding the ocular symptoms and a notion of purpuric spots on the lower limbs 3 months ago. Distance visual acuity has been rated at 1/10 on the right and counts the fingers on the left. Examination of the anterior segment mainly revealed periorbital ecchymosis and diffuse bilateral subconjunctival hemorrhage. Fundus analysis revealed bilateral diffuse retinal hemorrhage, premacular retro-hyaloid hemorrhage on the right and macular hemorrhage on the left. An emergency blood count showed anemia with hemoglobin (Hb) level of 5.5g/dL and thrombocytopenia at 15,000/µL. Hyperleukocytosis at 126420/µL with monocytes at 84700/µL and neutrophils at 3312/µL. The patient was immediately referred to a hematologist and an oncologist. The investigations and the myelogram made it possible to make the diagnosis of acute myeloid leukemia. Conclusions: Although the ophthalmologist plays a secondary role in the treatment of leukemia, he must be able to recognize the eye symptoms indicative of systemic disease and collaborate with hematologists and oncologists in the follow-up and management of patients.