Bilateral retinal detachments in thrombotic thrombocytopenic purpura

PROFOUND VISUAL RECOVERY AT 16 MONTHS AFTER RESOLUTION OF SEROUS RETINAL DETACHMENTS SECONDARY TO THROMBOTIC THROMBOCYTOPENIC PURPURA: CASE REPORT AND LITERATURE REVIEW

PURPOSE

To report a unique case of dramatic improvement in objective visual function during the recovery phase, after resolution of thrombotic thrombocytopenic purpura-related serous retinal detachments and to review prognostic trends in reported cases involving the macula.

METHODS

Observational case report and literature review.

RESULTS

A 36-year-old white woman with thrombotic thrombocytopenic purpura developed vision loss from serous retinal detachments in both eyes. Over a 16-month period, after both retinae remained attached, best-corrected visual acuity improved from 20/400 to 20/50 in both eyes with dramatic improvement on optical coherence tomography and autofluorescence imaging.

CONCLUSION

Although thrombotic thrombocytopenic purpura is a life-threatening illness, visual prognosis in patients with macula off serous retinal detachments appears excellent. Most cases reviewed in literature improved to baseline visual acuity, but recovery periods ranged from days to many months. Hyperautofluorescent granularity on autofluorescence photography may be an indicator of chronic retinal detachment and a more delayed visual recovery.

Bilateral exudative retinal detachments due to thrombotic microangiopathy associated with intravenous abuse of Opana ER

Purpose

To report the only known case, to our knowledge, of bilateral exudative retinal detachments in the setting of thrombotic microangiopathy associated with intravenous abuse of extended-release oxymorphone (Opana ER).

Observations

A 35-year-old male presented with headaches and acute, painless vision loss in the context of daily IV abuse of crushed oral Opana ER. The patient was found to have microangiopathic hemolytic anemia (MAHA), acute kidney injury in conjunction with hypertensive crisis and bilateral exudative retinal detachments.

Conclusions and importance

Bilateral exudative retinal detachments are rare ophthalmic complications that have been reported with thrombotic thrombocytopenic purpura (TTP). Non-TTP thrombotic microangiopathy, initially described as a “TTP-like illness” consisting of MAHA and thrombocytopenia, has been associated with the IV abuse of Opana ER. We report a case of bilateral exudative retinal detachments due to thrombotic microangiopathy in the setting of IV abuse of Opana ER.

Exudative Retinal Detachment Treatment in a Patient with Thrombotic Thrombocytopenic Purpura

Purpose

We report a case of unilateral exudative retinal detachment in a patient with thrombotic thrombocytopenic purpura (TTP), without associated hypertension, successfully treated with plasmapheresis.

Case Report

A 46-year-old woman with a medical history of TTP presented with unilateral exudative retinal detachment. Biological and radiological assessment eliminated other causes of exudative retinal detachment, including hypertension. Plasma exchange was performed, followed by a rapid improvement in visual acuity and total disappearance of serous detachment.

Conclusion

Exudative unilateral retinal detachment is a rare complication of TTP and can be successfully treated by plasma exchange.

Delayed visual recovery in pregnancy-associated thrombotic thrombocytopenic purpura with bilateral serous retinal detachment

BACKGROUND

To present a pregnancy-associated thrombotic thrombocytopenic purpura (TTP) patient with bilateral serous retinal detachment (SRD).

METHODS

Case report.

RESULTS

A 28-year-old nulliparous woman with 31 weeks gestation was presented to the local hospital with preeclampsia, hemolytic anemia, thrombocytopenia and bilateral blurry vision. Funduscopic examination showed bilateral macular SRD. Within the first month after delivery of a live female baby via cesarean section (at 32 weeks gestation), the patient experienced a recurrent course of hemolytic anemia and thrombocytopenia, and was then transferred to our hospital. On admission, her best corrected visual acuity (BCVA) was 0.1 OU; optical coherence tomography (OCT) confirmed the presence of bilateral macular SRD; electroretinography (ERG) examination showed diminished rod responses with reduced a and b waves in cone and mixed rod-cone responses. She was ultimately diagnosed with TTP and was treated systemically with fresh frozen plasma, rituximab, prednisone and cyclophosphamide. Despite persistent visual disturbances, she was discharged 1 month after admission with stabilization of systemic manifestations. At her first follow-up visit 6 months after discharge, surprisingly, her BCVA had improved to 1.0 OU; fundus examination and OCT confirmed the complete resolution of bilateral macular SRD and ERG revealed subnormal (right) and normal (left) electrophysiological responses. We believe that in this case, the clinical context (pregnancy) in which TTP developed, the unreported ERG characteristics and the unexpected delayed visual recovery are worth reporting.

CONCLUSIONS

TTP should be considered as a potential differential diagnosis in patients with pregnancy-associated SRD. Appropriate systemic treatment might be mandatory for visual recovery.

Unilateral serous retinal detachment in a patient with thrombotic thrombocytopenic purpura

Ocular complications are a relatively common occurrence in patients with thrombotic thrombocytopenic purpura (TTP). Serous retinal detachment is a rare but reported complication, with most cases being bilateral and associated with concomitant hypertension. Therapeutic plasma exchange has been used to successfully treat patients with TTP. We report a case of a 46 year old woman who presented with TTP, received therapeutic plasma exchange, and developed unilateral serous retinal detachment with retinal pigment epithelial tear in the absence of reported hypertension. The increased perfusion pressure due to hypertension, combined with the choroidal vasculature damage from TTP are thought to lead to retinal epithelial tear. This suggests that although hypertension may play a role in retinal detachment in these patients, other mechanisms may be responsible.

Combination vincristine and plasma exchange as initial therapy in patients with thrombotic thrombocytopenic purpura: one institution's experience and review of the literature

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) was once a highly fatal disease with mortality reaching nearly 95 percent; however, application of therapeutic plasma exchange (TPE) has dramatically increased survival. Nevertheless, mortality remains substantial (10%-30% in many published reports), requiring the search for more efficacious treatments. Vincristine (VCR) has been generally reserved for refractory TTP. Despite its effectiveness in a salvage mode, VCR has not been widely advocated as first-line therapy in conjunction with TPE. We previously reported improved survival when VCR and TPE were administered at presentation in patients treated from 1979 to 1994. Utilizing this standardized approach, outcomes of an additional group of patients and the results of a literature review of VCR therapy for TTP are reported.

STUDY DESIGN AND METHODS

Medical records of all patients with a diagnosis of TTP treated between 1995 and 2002 at Cedars-Sinai Medical Center were reviewed. TPE was performed daily, exchanging 1.25 plasma volumes, until the platelet count normalized. Patients received VCR 1.4 mg/m2, (up to 2.0 mg total dose) after the first TPE. A literature review of all publications utilizing VCR in the management of TTP was performed with MEDLINE.

RESULTS

Twelve consecutive patients meeting the diagnostic criteria received treatment with VCR and TPE. All patients achieved durable remission. Patients tolerated VCR without significant complications.

CONCLUSION

Our 100 percent survival rate, as well as evidence garnered from the literature review, suggests that combination therapy with VCR and TPE at presentation might be more effective than TPE alone and therefore warrants consideration as first-line therapy for TTP patients.

810 nm diode grid laser treatment for massive chronic serous retinal detachment following combined kidney and pancreas organ transplantation

An insulin-dependent diabetic woman of 42 years received a combined pancreas and kidney transplant five years prior to referral to our clinic for ophthalmic consultation. Her systemic immunosupression included oral steroids and she subsequently developed huge bilateral central serous retinal detachments affecting both posterior poles and the temporal midperiphery of the left eye. Her vision was reduced to count fingers (CF) in both eyes. Fluorescein angiography (FA) revealed diffuse mild retinal pigment epithelium (RPE) staining in both eyes. As an empiric treatment grid laser photocoagulation with an 810 nm diode laser (Iridex Corp., Mountain View, California) was performed with complete resorption of subretinal fluid in both eyes and visual improvement to 20/70 in the right eye and 20/200 in the left eye at 18 months post-treatment. In patients diagnosed with atypical central serous retinal detachment whose fluorescein angiogram displays widespread RPE damage and in whom systemic steroids are medically necessary, diode grid laser photocoagulation may be a reasonable treatment option.

Central serous chorioretinopathy and glucocorticoids

Central serous chorioretinopathy is a relatively common retinal disease characterized by the accumulation of subretinal fluid at the posterior pole of the fundus, creating a circumscribed area of serous retinal detachment. It typically affects young and middle-aged men with no previous medical and family history, and no systemic symptoms or signs. However, it has been noted that central serous chorioretinopathy is associated with different conditions, characterized by exposure to increased levels of endogenous or exogenous glucocorticoids. In fact, central serous chorioretinopathy has been described in patients with endogenous Cushing's syndrome. It is also prevalent in patients with type-A behavior, and following stressful events, and pregnancy probably represents a risk factor for central serous chorioretinopathy; these conditions are characterized by endogenous hypercortisolism. In addition, many cases of central serous chorioretinopathy have been described during or following treatment with glucocorticoids, administrated by any route, for various systemic or ocular conditions. Central serous chorioretinopathy, when related to the exposure to exogenous glucocorticoids, has a less prominent male predilection, presents more often with a chronic or atypical form, and is frequently bilateral. Furthermore, treatment of central serous chorioretinopathy with glucocorticoids was found to exacerbate the clinical picture. Based on these observations it could be suggested that glucocorticoids may be involved in the development of central serous chorioretinopathy, even though the exact pathogenic mechanism remains unclear. Glucocorticoids should not be used in the treatment of central serous chorioretinopathy and central serous chorioretinopathy should be added to the list of ocular complications of glucocorticoids.

Serous retinal detachment as an early presentation of thrombotic thrombocytopenic purpura

A 23-year-old woman presented with abdominal pain and blurred vision in both eyes. Fundoscopy revealed large bullous detachments of her neurosensory retina with shifting subretinal fluids bilaterally. Laboratory studies showed a hemoglobin of 6.5 mmol/l, thrombocytes 20x10(9)/l, and LDH 1098 U/l. A peripheral blood smear revealed red blood cell fragmentation. A diagnosis of thrombotic thrombocytopenic purpura was made. The patient was treated with four sessions of plasmapheresis followed by plasma infusions, which resulted in a complete recovery.