Diffuse Retinal Hemorrhages Research Articles

Central Retinal Vein Occlusion Secondary to Bonnet-Dechaume-Blanc Syndrome

A 23-year-old woman with Bonnet-Dechaume-Blanc syndrome recognized by arteriovenous malformations in the retina (Fig A) and the right suprasellar region reported an acute onset of blurred vision with visual acuity deteriorating from 20/60 to counting finger at 20 cm. Dilated examination revealed central retinal vein occlusion related to the arteriovenous abnormality (Fig B). Intravitreal implantation of slow-release dexamethasone was performed (Fig C). The diffuse retinal flame-shaped hemorrhages and the vascular tortuosity were reduced (Fig D).

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.

Determining the Tractional Forces on Vitreoretinal Interface Using a Computer Simulation Model in Abusive Head Trauma

Abusive head trauma (AHT) is the leading cause of infant death and long-term morbidity from injury. The ocular consequences of AHT are controversial, and the pathophysiology of retinal research findings is still not clearly understood. It has been postulated that vitreoretinal traction plays a major role in the retinal findings. A computer simulation model was developed to evaluate the vitreoretinal traction and determine whether the distribution of forces in different layers and locations of the retina can explain the patterns of retinal hemorrhage (RH) seen in AHT. Computer simulation model study. A computer simulation model of the pediatric eye was developed to evaluate preretinal, intraretinal, and subretinal stresses during repetitive shaking. This model was also used to examine the forces applied to various segments along blood vessels. Calculated stress values from the computer simulation ranged from 3-16kPa at the vitreoretinal interface through a cycle of shaking. Maximal stress was observed at the periphery of the retina, corresponding to areas of multiple vessel bifurcations, followed by the posterior pole of the retina. Stress values were similar throughout all 3 layers of the retina (preretinal, intraretinal, and subretinal layers). Ocular manifestations from AHT revealed unique retinal characteristics. The model predicted stress patterns consistent with the diffuse retinal hemorrhages (RH) typically found in the posterior pole and around the peripheral retina in AHT. This computer model demonstrated that similar stress forces were produced in different layers of the retina, consistent with the finding that retinal hemorrhages are often found in multiple layers of the retina. These data can help explain the RH patterns commonly found in AHT.

Atypical ophthalmic manifestations of disseminated intravascular coagulation in a newborn

Ophthalmic manifestations of disseminated intravascular coagulation (DIC) in a newborn are rare. Ocular involvement typically involves the posterior segment bilaterally and manifests as choroidal and/or retinal hemorrhages associated with fibrin thrombi in the choriocapillaris. We present the case of a newborn girl with DIC secondary to sepsis who subsequently developed nonclearing hyphema, related secondary cataract, 360° posterior synechiae, and nonclearing vitreous hemorrhage in the right eye and diffuse retinal hemorrhage in the left eye. The right fundus was not visible because of intraocular bleeding. The patient underwent cataract surgery at 39days of life and was left aphakic. Two weeks later, she required subsequent vitrectomy because of a nonclearing vitreous hemorrhage. She developed amblyopia of the right eye and a right esotropia that required strabismus surgery. At 7years of age, the patient's visual acuity was 20/50 in the right eye and 20/20 in the left eye.

Ophthalmic Artery Occlusion From Injection of Heroin Into the Forehead

Purpose: To report a case of ophthalmic artery occlusion after injection of heroin into the forehead. Methods: Retrospective case report. Results: A 27-year-old patient with a history of intravenous heroin abuse presented with a left ophthalmic artery occlusion after attempting to inject heroin into a vein in her forehead. Exam was significant for diffuse retinal edema, disc edema, disc hemorrhage, and diffuse retinal hemorrhages. Findings were also noted in the widefield image, optical coherence tomography, and optical coherence tomography angiography of the retina. Conclusions: This patient suffered from a severe form of talc retinopathy resulting in an ophthalmic artery occlusion after injecting heroin into her forehead. To our knowledge, this is the first instance of combined ophthalmic artery occlusion and talc retinopathy resulting from intentional injection into a superficial facial vein.

Very delayed onset, asymmetrical radiation retinopathy after external beam irradiation for nasopharyngeal carcinoma: a case report

Background: Radiation retinopathy is a chronic, gradually progressive retinal microangiopathy that can occur with variable latency after exposure to radiation of head and neck. Nasophargeal carcinoma is a frequent head and neck tumor of the south-East Asian countries. Case Presentation: A 54-year old Asian male presented with decreased vision for 2 years in left eye. He had diffuse cystoid macular edema, retinal hemorrhages, exudates, and telangiectatic vessels. In the right eye, he had focal macular edema, exudates, and micro-aneurysm. He had undergone external beam radiation for nasopharyngeal carcinoma 32 years ago. He was treated with several injections of Anti-vascular endothelial growth factors elsewhere for persistent macular edema secondary to vein occlusion in the left eye, and had fewer response. Conclusion: The chronic maculopathy responded to treatment with intra vitreal sustained-release dexamethasone implant (Ozurdex®) and laser photo coagulation.

Postoperative Hemorrhagic Occlusive Retinal Vasculitis Associated with Intravitreal Injection of Vancomycin

PURPOSE: To present a case of hemorrhagic occlusive retinal vasculitis (HORV) associated with intravitreal injection of vancomycin after pars plana vitrectomy (PPV).METHODS: Single case report.RESULTS: A 67-year-old woman presented with best corrected visual acuity (BCVA) of 20/400 in left eye. For clinical suspicion of chronic endophthalmitis, empirical treatment was initiated with vancomycin and ceftazidime without clinical improvement. The patient was submitted to pars plana vitrectomy. During surgery rhegmatogenous retinal detachment was observed and treated. At the end of surgery, intravitreal vancomycin was injected. After 18 days BCVA was counting fingers and fundus examination showed diffuse retinal vascular sheathing, intraretinal hemorrhages and ischemic macular whitening. The clinical diagnosis was compatible with HORV secondary to retinal toxicity due to intraocular vancomycin.CONCLUSIONS: This case illustrates the importance of including intravitreal vancomycin during PPV surgery on the list of potential causes when investigating a case of suspected hemorrhagic occlusive retinal vasculitis.

Clinical comparison of ocular and systemic findings in diagnosed cases of abusive and non-abusive head trauma

PurposeChild abuse is a leading cause of death in infants, which is often associated with abusive head trauma (AHT). The purpose of this retrospective analysis was to identify ocular and systemic findings in confirmed cases of AHT and compare them to a group of non-abusive head trauma (NAHT) patients.Patients and methodsA retrospective chart review of 165 patients with accidental and non-accidental trauma admitted between 2013 and 2015 to Children’s Hospital and Medical Center in Omaha, NE, USA, was performed. Diagnosis of AHT was made after the analysis of ocular and systemic findings by various subspecialists. The NAHT group consisted of accidental trauma, abusive trauma without significant apparent head involvement on initial evaluation and unconfirmed AHT cases.ResultsOf the 165 presenting cases, 30 patients were diagnosed with AHT and 127 were diagnosed with NAHT. Ocular findings in AHT patients were significant for retinal hemorrhages (63%) and vitreous hemorrhages (37%), while NAHT patients had no ocular findings (p<0.001). Neuroimaging revealed subdural hemorrhages (SDHs) in 29 out of 30 AHT patients (97%) and in 27 out of 127 NAHT patients (21%). Seizures were present in 43% of AHT patients (n=13) and only in 8% of NAHT patients (n=10).ConclusionAHT has statistically significant findings of retinal and vitreous hemorrhages. The absence of diffuse retinal hemorrhages, however, does not preclude the AHT diagnosis as more than one-third of AHT patients lacked retinal hemorrhages. SDHs, loss of consciousness and history of seizures also have high correlation with a diagnosis of AHT.

Cyclic Head Rotations Produce Modest Brain Injury in Infant Piglets.

Repetitive back-and-forth head rotation from vigorous shaking is purported to be a central mechanism responsible for diffuse white matter injury, subdural hemorrhage, and retinal hemorrhage in some cases of abusive head trauma (AHT) in young children. Although animal studies have identified mechanisms of traumatic brain injury (TBI) associated with single rapid head acceleration-decelerations at levels experienced in a motor vehicle crash, few experimental studies have investigated TBI from repetitive head rotations. The objective of this study was to systematically investigate the post-injury pathological time-course after cyclic, low-velocity head rotations in the piglet and compare them with single head rotations. Injury metrics were the occurrence and extent of axonal injury (AI), extra-axial hemorrhage (EAH), red cell neuronal/axonal change (RCNAC), and ocular injury (OI). Hyperflexion/extension of the neck were purposefully avoided in the study, resulting in unscaled angular accelerations at the lower end of reported infant surrogate shaking kinematics. All findings were at the mild end of the injury spectrum, with no significant findings at 6 h post-injury. Cyclic head rotations, however, produced modest AI that significantly increased with time post-injury (p < 0.035) and had significantly greater amounts of RCNAC and EAH than noncyclic head rotations after 24 h post-injury (p < 0.05). No OI was observed. Future studies should investigate the contributions of additional physiological and mechanical features associated with AHT (e.g., hyperflexion/extension, increased intracranial pressure from crying or thoracic compression, and more than two cyclic episodes) to enhance our understanding of the causality between proposed mechanistic factors and AHT in infants.

Diffuse bilateral retinal hemorrhages in an infant with a coagulopathy and prolonged cardiopulmonary resuscitation

We report a case of diffuse bilateral retinal and optic nerve sheath hemorrhages in an 8-week-old boy who was found unresponsive. The child underwent prolonged cardiopulmonary resuscitation andwas noted on admission to have a coagulopathy. An autopsy determined the cause of death to be a myocardial infarct in the distribution of an anomalous coronary artery. This case demonstrates the difficulty that may occur in establishing whether child abuse caused death in the setting of another potential cause of mortality.

Bilateral Simultaneous Central Retinal Vein Occlusion in a Patient with Waldenstrom's Macroglobulinemia

Purpose: The authors report a case of bilateral simultaneous central retinal vein occlusion caused by Waldenstrom’s macroglobulinemia. Case summary: A 65-year-old man presented to our department complaining of decreased visual acuity for the duration of about 6 months. On his initial visit, best-corrected visual acuity was 0.02 in the right eye and 0.06 in the left eye. Based on the findings of a funduscopic examination, the patient had bilateral diffuse retinal hemorrhages, dilated tortuous veins, and macular edema. He had experienced recurrent spontaneous epistaxis 6 months previously and had undergone treatments such as intravitreal bevacizumab injection and intravitreal dexamethasone implantation at another hospital. Laboratory tests at that hospital showed anemia and hyperproteinemia, for which he was referred to our hemato-oncology department. Bone marrow biopsy was consistent with Waldenstrom’s macroglobulinemia/lymphoplasmacytoid lymphoma, and he was treated with systemic chemotherapy. One year after the systemic chemotherapy, his best-corrected visual acuity was 0.15 in the right eye and 0.6 in the left eye. Funduscopy showed decreased bilateral retinal hemorrhages and macular edema. Conclusions: When simultaneous bilateral central retinal vein occlusion occurs in a patient with no other underlying disease such as hypertension or diabetes, it might be a sign of serum hyperviscosity, and there should be a very high level of suspicion for presence or progression of systemic disease. If such a disease is properly and timely diagnosed, effective early systemic evaluation and therapy can be administered, and it is important to have initial general treatment as well as ophthalmic treatment. J Korean Ophthalmol Soc 2016;57(6):1012-1017

White center retinal hemorrhages revealing acute lymphoblastic leukemia

AbstractPurpose Acute lymphoblastic leukemia is a severe affection related to invasion of the bone marrow by immature haematopoietic cells of the lymphoid lineage. Retinal hemorrhages with white center are secondary to a specific pathophysiological mechanism. They are exceptional when revealed acute leukemia.Methods Through clinical observation of a case of acute lymphocytic leukemia revealed by retinal hemorrhages with white center, we recall the pathophysiological mechanisms and clinical aspects of this rare retinal disease.Results A 16 years old child consult for myodesopsia in his left eye. The ophtalmological examination show a correct visual acuity 10/10 P2 in the right eye and 9/10 P2 in the left. We note a discolored conjunctiva with vascular occlusions. The examination of the fundus of eyes reveal a diffuse retinal hemorrhages with white center. The blood count analysis show ; 120.000/mm3 WBC, Hb 3.5 g / dl and platelet 37.000/mm3. The diagnosis of acute lymphoblastic leukemia is made. The child is cared for in a pediatric oncology service. He received a blood transfusion and chemotherapy with complete remission at the last control.Conclusion Ophthalmologic examination has a major interest in the diagnostic and therapeutic management of this disease.

Blinding bilateral hyperviscosity retinopathy in a 43-year-old nigerian male with lymphoplasmacytic lymphoma: a case report and management challenges.

Lymphoplasmacytic lymphomas are rare and may present with uncommon and devastating symptoms. We report a case of a 43-year-old male who presented with bleeding gums and sudden onset of bilateral blindness but was not on anticoagulants and had no family history of bleeding disorder. He had bilateral hyperpigmented infraorbital skin lesions, visual acuities (VA) of hand motion in both eyes (blindness), round and sluggish pupils, and bilateral diffuse and extensive retinal haemorrhages obliterating the retinal details with central visual field defects. The optical coherence tomography revealed retinal haemorrhage, oedema, detachment, and diffuse photoreceptors damage. Investigations revealed elevated ESR and β 2 microglobulin, monoclonal peak on serum protein electrophoresis, high IG with lambda restriction on serum, and urine immunofixation with increased lymphocytes and plasma cells in the bone marrow. A diagnosis of lymphoplasmacytic lymphoma complicated by blinding hyperviscosity retinopathy was made. In the absence of an aphaeresis machine, he received four cycles of manual exchange blood transfusion (EBT) and commenced with chlorambucil/prednisolone due to difficulty in obtaining blood for continued EBT. His general condition and VA has improved and he is stable for more than six months into treatment.

Spontaneous closure of traumatic macular hole

Macular hole formation is a well-known complication following ocular trauma. Less commonly recognised is the spontaneous closure of such holes.A 27-year-old man presented with a history of blunt trauma to his left eye. Eye evaluation showed conjunctival laceration, diffuse retinal oedema and multiple retinal haemorrhages in that eye. A month later, he developed a full thickness macular hole. Two months later, there was spontaneous complete closure of the full-thickness macular hole in the left eye as confirmed on optical coherence tomography.Spontaneous closure of hole is not uncommon. Observation for a period of up to 12months is a reasonable management option. Macular hole surgery for traumatic macular holes may be delayed in such cases.

Unusual retinal manifestations of cat scratch disease

We report on 2 patients with unusual retinal manifestations of cat scratch disease (CSD), caused by Bartonella henselae. Case 1. A 42-year-old farmer presented with a 5-day history of blurred vision in his right eye. Right visual acuity was 20/25. Fundus examination of the right eye revealed mild vitreous hemorrhage and diffuse retinal hemorrhages in the mid-peripheral retina. Fluorescein angiography showed multiple vasculitic occlusions in the same area. A blood sample taken on the day of examination revealed the presence of immunoglobulin (Ig)M and IgG to B. henselae. Oral azithromycin was given for 8 days. One month later, right visual acuity was 20/20, the vitreous and retinal hemorrhages resolved, and arteriolar attenuation and sclerosis was observed in the peripheral temporal retina. Case 2. A 66-year-old craftsman with systemic hypertension and hypercholesterolemia complained of sudden visual loss (light perception) in his left eye. Fundus evaluation and fluorescein angiography revealed central retinal artery occlusion (CRAO) in the affected eye. About 2 weeks earlier, he had been bitten and scratched on his right hand by a stray cat. Serologic testing detected the presence of IgM to B. henselae. Oral azithromycin was given for 6 days. One month later, left visual acuity was hand motion. Ophthalmologists should be aware that unusual ocular complications associated with CSD include vitreous hemorrhage with retinal vasculitis and isolated CRAO. Vitreous hemorrhage and retinal vasculitis may be the only clinical manifestation of CSD.

Sequential Anterior Ischemic Optic Neuropathy and Central Retinal Artery and Vein Occlusion after Ranibizumab for Diabetic Macular Edema

To describe a rare adverse event characterized by anterior ischemic optic neuropathy (AION) associated with central retinal artery occlusion (CRAO) followed by central retinal vein occlusion (CRVO) secondary to treatment with intravitreal injection of ranibizumab for diabetic macular edema (DME). A patient with DME refractory to focal grid laser photocoagulation in the left eye was prospectively followed and treated with intravitreal injection of ranibizumab. Over a 12-month period and after 4 injections, best-corrected visual acuity (BCVA) improved from 20/63 to 20/50 (Snellen equivalent) and central retinal thickness (CRT) reduced from 551 to 279 µm. In July 2009, BCVA dropped to 20/100 with CRT of 421 µm due to the recurrence of DME and a further injection was administered. One month later, the left eye showed a sudden visual acuity loss. Best-corrected visual acuity was 20/400 and the fundus examination revealed a hyperemic and swollen optic disc, with several retinal hemorrhages. Retina at the posterior pole was pale, with attenuation and sheathing of arterial vessels. Fluorescein angiography showed a delayed optic disc and arterial filling with retinal ischemia involving both posterior pole and periphery and confirmed the diagnosis of AION associated with CRAO. One month later, the BCVA decreased to 20/800, and fundus examination evidenced a CRVO with diffuse retinal hemorrhages in the 4 quadrants, congestion, and tortuosity of the retinal veins. Although severe ocular adverse events are generally rare, patients receiving intraocular anti-vascular endothelial growth factor injection should be monitored carefully for the development of vascular complications.

Bilateral circumferential macular folds in inflicted childhood neurotrauma.

To report an infant with inflicted neurotrauma who exhibited bilateral circumferential macular folds. Bedside ophthalmic examination and fundus photography using RetCam-II (Clarity Medical Systems, Pleasanton, CA). Both pupils were miotic and nonreactive. External and anterior segments showed no abnormality. The fundus showed bilateral diffuse multilaminar retinal, subhyaloid, and vitreous hemorrhages. Distinctive macular folds were noted bilaterally. Circumferential macular folds are most commonly found in abused infants, although it has been suggested that they may be associated with Terson syndrome and severe crush injury.

Vitreous haemorrhage and retinal vasculitis as manifestations of cat‐scratch disease

Abstract Purpose To report a rare case of vitreous haemorrhage and retinal vasculitis secondary to cat scratch disease, caused by Bartonella henselae. Methods A 42‐year‐old apparently healthy farmer presented with a 5‐day history of blurred vision in his right eye. Right visual acuity was 20/25. Slit‐lamp examination of the right eye revealed mild vitreous haemorrhage and diffuse retinal haemorrhages in the middle‐peripheral retina. The left eye was unremarkable. Fluorescein angiography showed signs of retinal vasculitis in the right eye. The patient owned several cats, but had no history of cat bites or scratches. Results A blood sample taken on the day of admission revealed the presence of IgM (titre=1:40) and IgG (titre=1:80) to B. henselae. Accordingly, the diagnosis of cat‐scratch disease was made. The retinal vasculitis resolved after 8 days of therapy with oral azithromycin. Conclusion Apart from neuroretinitis, the ocular complication associated with cat‐scratch disease may include vitreous haemorrhage and retinal vasculitis.

Bilateral serous macular detachments in Waldenström’s macroglobulinaemia

A 71-year-old man presented to the emergency department with reduced vision in the right eye of 4 weeks duration. He complained of hazy and distorted vision, shortness of breath, and...

Central retinal vein occlusion in primary antiphospholipid antibody syndrome.

To report a case of a 20-year-old healthy patient with central retinal vein occlusion in his right eye attributable to primary antiphospholipid antibody syndrome. A 20-year-old man with poor vision in the right eye and diffuse retinal hemorrhages was investigated for infections, autoimmune disease, diabetes, and hypertension. Testing for homocysteine, anticardiolipin antibodies, lupus anticoagulant, and functional assays for protein S and protein C was performed to detect a hypercoagulable state. Laboratory investigations revealed elevated levels of IgG and M anticardiolipin antibodies. Long-term oral anticoagulants were given to reduce the risk of future thromboses. Antiphospholipid antibodies play an important role in occlusive retinal vascular disorders, especially in young patients without any conventional risk factors.