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Sir,

We read with interest Rennie's series of premacular subhyaloid haemorrhage treated successfully with Nd:YAG laser in the August 2001 issue.1 The causes of the haemorrhage in their series included Valslava retinopathy, macroaneurysm, branch vein occlusion, proliferative diabetic retinopathy and idiopathic. We describe here a case of bilateral premacular subhyaloid haemorrhage as a result of chemotherapy-induced pancytopenia.

Case report

A 59-year-old Asian man was referred to the Eye Department 2 weeks after developing sudden deterioration of vision in both eyes. A diagnosis of Stage IV B Mixed Cellularity Hodgkin's lymphoma had been made 6 months previously and chemotherapy had been commenced using the ChlVPP/PABLOE regime (chlorambucil, vinblastine, carbazine, prednisoline/prednisolone, adriamycin, bleomycin, vincristine, etoposide). The second chemotherapy treatment was given 10 days before the onset of his ophthalmic symptoms. This was complicated by post-chemotherapy pancytopenia, resulting in a haemoglobin of 6.6 g/dl, a white cell count of 0.4×109/l, and a platelet count of 17×109/l. Five units of packed cells and one unit of platelets were transfused, which returned the haemoglobin count to 12.2 g/dl, white cell count to 3.5×109/l, and platelet count to 58×109/l.

On examination, his visual acuity was hand movements in the right eye and 6/60 in the left, with no pinhole improvement. The anterior segments and intraocular pressures were normal. Fundoscopy reviewed multiple areas of dense round intraretinal haemorrhages, measuring one-quarter to two disc diameters in size in both eyes. There were alsobilateral premacular subhyaloid haemorrhages(Figures 1 and 2).

Figure 1
figure 1

Fundus photograph of the left eye showing well-circumscribed sub-internal limiting membrane haemorrhages, including a large premacular haemorrhage.

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Figure 2
figure 2

Fundus photograph of the right eye showing similar haemorrhages to the left eye, also including a large premacular haemorrhage.

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Nd:YAG laser membranotomy was performed in the right eye at 3 weeks after the initial symptoms. The internal limiting membrane was visibly punctured but no dispersion of blood was seen during the procedure. At 1 week follow-up, there was no change in the visual acuity or fundal appearance. Urgent vitrectomy was arranged, but the patient died from Hodgkin's lymphoma before the operation.

Comment

This case reports an unusual cause of premacular haemorrhage. The patient suffered from Hodgkin's lymphoma and the onset of symptoms coincided with the development of post-chemotherapy pancytopenia.

Although Nd:YAG laser membranotomy has been well described as an effective mode of treatment, the success rate varies, depending on the cause and the timing of the treatment.1,2,3,4 Complications including macular hole and retinal detachment have been described.3,4,5 There has been no study into the time frame for such laser treatment in the literature. We speculate that the failure of the laser treatment in this case is due to the 3-week delay between symptom onset and treatment, during which time the blood had clotted under the internal limiting membrane.

We conclude that premacular haemorrhage should be considered as a complication of chemotherapy-induced cytopenia. Patients should be assessed urgently by an ophthalmologist and Nd:YAG membranotomy should be considered as there is a small window of time in which laser treatment has the highest chance of success. Delay in treatment can significantly reduce the chance of restoring vision in patients who have limited life expectancy.