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Paper text:
idiopathic thrombocytopenic purpura ( itp ) is an autoimmune disorder in which antibodies are directed against platelet surface antigens , causing a characteristic purpuric rash , or bleeding .
ophthalmic involvement is exceptionally rare.1 we report a patient with itp who developed spontaneous bilateral peripapillary , subhyaloid and vitreous hemorrhage with only minor platelet deficit .
a 45-year - old female with underlying itp and diabetes mellitus presented to the department of ophthalmology , hospital raja perempuan zainab ii , complaining of a sudden onset of reduced vision in both eyes , of about 3 weeks in duration .
there was no history of trauma , intense aerobic exercise , heavy lifting , straining on the toilet , vomiting , coughing , or vigorous sexual activity .
she had been diagnosed with itp several years before , with initial presentation of menorrhagia .
examination revealed visual acuity of 6/36 and 6/60 in the right and left eyes , respectively .
fundus examination showed bilateral peripapillary , subhyaloid and vitreous hemorrhage , which was more pronounced in the left eye ( figure 1 ) .
the patient s platelet count was 12010/l ( normal : 15045010/l ) ; her hemoglobin count was 93
after consultation by a hematologist , she was treated with oral prednisolone , starting dose of 50 mg daily ( 1 mg / kg / day ) for 1 week .
review at 6 weeks showed spontaneous partial resolving of hemorrhages ( figure 2 ) , and slight improvement of vision ( to 6/24  both eyes ) .
it was recommended to the patient that she undergo left eye vitrectomy ( in view of the fact the subhyaloid hemorrhage was just adjacent to the macula ) , but the patient has not yet consented to the operation .
itp is an autoimmune hematological disease wherein circulating antibodies direct activity against host platelet surface antigens causing platelet destruction , thereby resulting in reduced platelet counts and subsequent complications of bleeding .
the common presentations of itp are bleeding from the skin , mucous membrane , gastrointestinal tract , central nervous system , and vagina.2,3 there are no large case series on the spectrum of findings on itp in eyes ; mostly , these are single - case reports .
ophthalmic manifestations associated with itp reported include vitreous hemorrhage,4 subconjunctival hemorrhage,5 massive subretinal hemorrhage with life - threatening intracranial hemorrhage,6 and vitreoretinal hemorrhages.79 majji et al,7 okuda et al,8 and pathengay et al9 have reported similar posterior segment findings in their case reports , which are also seen in our patient .
it has been reported by rubenstein et al that there is a high incidence of retinal hemorrhage in patients with severe anemia ( < 80
g / l ) and severe thrombocytopenia ( < 5010/l ) , but a much lower frequency in anemic patients without thrombocytopenia.10 however , this is not what we had observed from this patient , who had only mild thrombocytopenia ( 12010/l ) and moderate anemia ( 93 g / l ) when she presented with ocular symptoms , in contrast to severe thrombocytopenia in other case reports ( 1210/l by majji et al ; 4210/l by pathengay et al ; and < 210/l by okuda et al).79 carraro et al demonstrated that retinopathy was closely associated with the conditions of severe anemia and severe , or very severe , thrombocytopenia.11 this patient was recommended to undergo left eye vitrectomy , to evacuate the subhyaloid hemorrhage that was threatening the macula ; but , she refused any surgical intervention .
similar findings were seen in majji et al s patient , in whom complete resolution of hemorrhages was noted after the patient had been managed through only systemic factors , without any invasive procedure.7 nevertheless , vitrectomy can be beneficial for massive vitreoretinal hemorrhages.8 okuda et al performed vitrectomy for a patient with itp who presented with massive bilateral vitreoretinal hemorrhage .
the patient s vision ( better eye ) improved from 6/90 to 6/30 after surgery .
a 45-year - old female with underlying idiopathic thrombocytopenic purpura ( itp ) complained of acute onset of reduced vision and floaters , in both eyes , for 3 weeks . 
 visual acuity was 6/36 and 6/60 in the right eye and left eye , respectively . 
 ophthalmoscopy showed bilateral peripapillary , subhyaloid and vitreous hemorrhage . 
 hematological evaluation revealed moderate anemia ( hemoglobin : 93 
 g / l ) and mild thrombocytopenia ( platelets : 120109/l ) . 
 she was co - managed by a hematologist and ophthalmologists ; she was treated medically . 
 follow - up care during the next 6 weeks revealed spontaneous , partially resolving hemorrhage , with improvement of visual acuity . 
 the purpose of this case report is to highlight ophthalmic involvement of itp in this patient , despite her only - mild thrombocytopenia , and her spontaneous recovery , despite her receiving only medical treatment .