Massive subretinal haemorrhage secondary to age-related macular degeneration in a patient with idiopathic thrombocytopenic purpura

Main

Sir,

Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by persistently low platelet counts, resulting from accelerated platelet destruction mediated by antiplatelet antibody. As ocular complication with ITP, hemianopia caused by intracranial haemorrhage, intraretinal haemorrhage caused by anaemia are reported.^1,2 An association between age-related macular degeneration (AMD) and ITP has not been reported to our knowledge. We describe a rare association between severe subretinal haemorrhage and ITP. Our case demonstrates that close ophthalmologic examination is very important in ITP.

Case report

A 73-year-old woman experienced a sudden loss of vision in the left eye and are referred to our macular clinic for a detailed examination. She had been followed up for exudative AMD and received cataract surgery with intraocular lens implantation at the age of 66 years. During the referring physician's recent observation, the visual acuity of the left eye was 0.1–0.3. Ophthalmoscopic examination (Figure 1a), fluorescein angiography, (Figure 1b) and indocyanine green angiography (Figure 1c) reavealed a persistent occult choroidal neovascular membrane not suitable for treatment. She also had a systemic previous history of diabetes mellitus, hypertension, and ITP. The platelet count was 7000/mm³. On our ophthalmologic examination, the visual acuity became 30 cm hand movements. The dilated fundus examination of the left eye revealed 7 × 10 disc diameter (DD) submacular haemorrhage (Figure 1d). Although fluorescein angiography failed to detect the cause of haemorrhage, indocyanine green angiography (ICG) disclosed a hyperfluorescent lesion indicative of choroidal neovascularization (CNV). Observation was recommended. After 1 month, massive haemorrhage developed so rapidly that it reached the posterior capsule of the lens as disclosed by B-mode ultrasonography (Figure 1e) and slit-lamp biomicroscopy (Figure 1f). The visual acuity dropped to light perception. Within the following week, the patient revisited us claiming of severe headache. The visual acuity was no light perception. The ocular pressure of the left eye was 63 mmHg. Slit-lamp examination showed a narrow anterior chamber, and dilated fundus examination and B-mode ultrasonography revealed total retinal detachment (Figure 1g).

Figure 1

Dilated fundus examination (a) revealed subretinal haemorrhage in the macular area at our recent observation. Fluorescein angiography (b) and indocyanine green angiography (c) disclosed a persistent occult choroidal membrane not suitable for treatment. At initial presentation to our clinic, the dilated fundus examination disclosed a massive subretinal haemorrhage (d). After 1 month, massive subretinal haemorrhage was seen as high reflex on B-mode ultrasonography (e) and slit-lamp examination showed massive subretinal haemorrhage reaching the posterior capsule of the lens (f). At 1 week thereafter, the subretinal haemorrhage reached the posterior capsule of the lens as shown by B-mode ultrasonography (g).

Comment

Massive subretinal haemorrhage is a serious complication of AMD. Systemic hypertension³ and the use of anticoagulants⁴ are known risk factors of subretinal haemorrhage. We describe a rare association between subretinal haemorrhage and ITP. This case indicates that close ophthalmologic examination is necessary for us to treat thrombocytopenic diseases like ITP.