Combined CRVO & CRAOCombined CRVO & CRAO

Mamta AgarwalMamta AgarwalSenior ConsultantSenior Consultant

Uveitis & Cornea ServicesUveitis & Cornea ServicesSankara NethralayaSankara Nethralaya

ChennaiChennai

Ocular HistoryOcular History 47 yr/F47 yr/F OD - C/O sudden, painless decrease OD - C/O sudden, painless decrease

in vision since 4 days in vision since 4 days H/O fever with rigors & chills H/O fever with rigors & chills

since 10 days, since 10 days, diagnosed as malariadiagnosed as malaria no other systemic illnessno other systemic illness

First PresentationFirst Presentation

BCVA OD – HM+ OS- 6/6BCVA OD – HM+ OS- 6/6 EOM Full, free, painlessEOM Full, free, painless Pupils OD - RAPD+Pupils OD - RAPD+ SLE OD – AC cells+, flare+ SLE OD – AC cells+, flare+ OS – quietOS – quiet IOP WNLIOP WNL

First Examination - FundusFirst Examination - Fundus

Fluorescein AngiographyFluorescein Angiography

Early Early MiddleMiddle LateLate delayed arterio-venous filling, delayed arterio-venous filling, marked hypofluorescence secondary to capillary non-perfusionmarked hypofluorescence secondary to capillary non-perfusion retinal hemorrhages and late staining of the discretinal hemorrhages and late staining of the disc

Blood test Blood test Plasmodium falciparum positive (QBC method)Plasmodium falciparum positive (QBC method) Hb Hb 6.5 gm%6.5 gm% Coagulation profile Coagulation profile normalnormal Sickling test Sickling test negativenegative cANCA, pANCA cANCA, pANCA negativenegative Antiphospholipid antibody – IgG & IgM negativeAntiphospholipid antibody – IgG & IgM negative

ERG – grossly reduced responses suggestive of ischemia ERG – grossly reduced responses suggestive of ischemia

Work UpWork Up

DiagnosisDiagnosis

Combined Combined CRVO & CRAO CRVO & CRAO

with malariawith malaria

TreatmentTreatment

Oral & topical corticosteroidsOral & topical corticosteroidsOral antimalarial ( Tab Falcigo)Oral antimalarial ( Tab Falcigo)Panretinal photocoagulationPanretinal photocoagulation

Follow up after 2 monthsFollow up after 2 months

BCVA CF 50cmsBCVA CF 50cms Fundus Vitreous hemorrhageFundus Vitreous hemorrhage

Treatment Transscleral CryotherapyTreatment Transscleral Cryotherapy

Follow Up after 6 MonthsFollow Up after 6 Months

BCVA – HM+BCVA – HM+Fundus Fundus

thickened thickened posterior posterior hyaloid & hyaloid & sclerosed vesselssclerosed vessels..

MalariaMalaria Malaria is caused by protozoan Malaria is caused by protozoan PlasmodiumPlasmodium, mostly, mostly

P. vivax & P. falciparum.P. vivax & P. falciparum.

WHO 2012 malaria reportWHO 2012 malaria report

219 million cases of malaria in 2010 and an estimated219 million cases of malaria in 2010 and an estimated

660 000 deaths (90% deaths in Africa)660 000 deaths (90% deaths in Africa)

India has the highest malaria burden (with an estimated India has the highest malaria burden (with an estimated

24 million cases per year) in South East Asia. 24 million cases per year) in South East Asia.

Ocular manifestationsOcular manifestations Ocular complications in patients with malaria have been Ocular complications in patients with malaria have been

reported in 10% - 20%. reported in 10% - 20%. Subconjunctival hemorrhage & conjunctival yellowish discolorationSubconjunctival hemorrhage & conjunctival yellowish discoloration

KeratitisKeratitis

Optic neuritis, peripapillary edemaOptic neuritis, peripapillary edema

Retinal whitening, hemorrhages, vessel abnormalities, papilledema, Retinal whitening, hemorrhages, vessel abnormalities, papilledema,

and cotton wool spots.and cotton wool spots.

Conclusion - MechanismConclusion - Mechanism Cyto-adherence of erythrocytes as well as parasitized Cyto-adherence of erythrocytes as well as parasitized

erythrocytes inside the choriocapillaries and retinal blood erythrocytes inside the choriocapillaries and retinal blood vessels cause inflammation that results in leakage and/or vessels cause inflammation that results in leakage and/or hemorrhages into surrounding tissues. hemorrhages into surrounding tissues.

Obstruction of capillaries by parasitized and subsequently Obstruction of capillaries by parasitized and subsequently deformed erythrocytes result in vessel occlusion.deformed erythrocytes result in vessel occlusion.

Hemolyzed erythrocytes and active parasitemia of the Hemolyzed erythrocytes and active parasitemia of the uveal tract may lead to uveitis.uveal tract may lead to uveitis.

ReferencesReferences Lewallen S. Ocular malaria. Ophthalmology. 1997;104:564-5. Lewallen S. Ocular malaria. Ophthalmology. 1997;104:564-5. Biswas et al. Ocular malaria. A clinical and histopathologic study. Biswas et al. Ocular malaria. A clinical and histopathologic study.

Ophthalmology. 1996 Sep;103:1471-5.Ophthalmology. 1996 Sep;103:1471-5. Hidayat et al. The diagnostic histopathologic features of ocular Hidayat et al. The diagnostic histopathologic features of ocular

malaria.Ophthalmology. 1993;100:1183-6.malaria.Ophthalmology. 1993;100:1183-6. Lewallen et al. Clinical-histopathological correlation of the abnormal Lewallen et al. Clinical-histopathological correlation of the abnormal

retinal vessels in cerebral malaria. Arch Ophthalmol. 2000 ;118:924-8.retinal vessels in cerebral malaria. Arch Ophthalmol. 2000 ;118:924-8. Beare NA et al. Beare NA et al. Malarial retinopathy: a newly established diagnostic Malarial retinopathy: a newly established diagnostic

sign in severe malariasign in severe malaria.. Am J Trop Med Hyg. 2006;75:790-7. Am J Trop Med Hyg. 2006;75:790-7.