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Combined CRVO & CRAO with Malaria: Case Study & Ocular Manifestations

This case study highlights a 47-year-old female diagnosed with both CRVO and CRAO alongside malaria, detailing examination findings, treatment, and ocular complications associated with malaria. Ocular manifestations and mechanisms are discussed with reference to relevant studies.

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Combined CRVO & CRAO with Malaria: Case Study & Ocular Manifestations

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  1. Combined CRVO & CRAO Mamta Agarwal Senior Consultant Uveitis & Cornea Services SankaraNethralaya Chennai

  2. Ocular History • 47 yr/F • OD - C/O sudden, painless decrease in vision since 4 days • H/O fever with rigors & chills since 10 days, • diagnosed as malaria • no other systemic illness

  3. First Presentation • BCVA OD – HM+ OS- 6/6 • EOM Full, free, painless • Pupils OD - RAPD+ • SLE OD – AC cells+, flare+ OS – quiet • IOP WNL

  4. First Examination - Fundus

  5. Fluorescein Angiography Early Middle Late • delayed arterio-venous filling, • marked hypofluorescence secondary to capillary non-perfusion • retinal hemorrhages and late staining of the disc

  6. Work Up • Blood test • Plasmodium falciparum positive (QBC method) • Hb 6.5 gm% • Coagulation profile normal • Sickling test negative • cANCA, pANCA negative • Antiphospholipid antibody – IgG & IgM negative • ERG – grossly reduced responses suggestive of ischemia

  7. Diagnosis Combined CRVO & CRAO with malaria

  8. Treatment • Oral & topical corticosteroids • Oral antimalarial ( Tab Falcigo) • Panretinal photocoagulation

  9. Follow up after 2 months • BCVA CF 50cms • Fundus Vitreous hemorrhage • Treatment Transscleral Cryotherapy

  10. Follow Up after 6 Months • BCVA – HM+ • Fundus • thickened posterior hyaloid & sclerosed vessels.

  11. Malaria • Malaria is caused by protozoan Plasmodium, mostly • P. vivax & P. falciparum. • WHO 2012 malaria report • 219 million cases of malaria in 2010 and an estimated • 660 000 deaths (90% deaths in Africa) • India has the highest malaria burden (with an estimated 24 million cases per year) in South East Asia.

  12. Ocular manifestations • Ocular complications in patients with malaria have been reportedin 10% - 20%. • Subconjunctival hemorrhage & conjunctival yellowish discoloration • Keratitis • Optic neuritis, peripapillaryedema • Retinal whitening, hemorrhages, vessel abnormalities, papilledema, and cotton wool spots.

  13. Conclusion - Mechanism • Cyto-adherence of erythrocytes as well as parasitized erythrocytes inside the choriocapillaries and retinal blood vesselscause inflammation that results in leakage and/or hemorrhages into surrounding tissues. • Obstruction of capillaries by parasitized and subsequently deformed erythrocytes result in vessel occlusion. • Hemolyzederythrocytes and active parasitemia of the uveal tract may lead to uveitis.

  14. References • LewallenS. Ocular malaria. Ophthalmology. 1997;104:564-5. • Biswas et al. Ocular malaria. A clinical and histopathologic study. Ophthalmology. 1996 Sep;103:1471-5. • Hidayat et al. The diagnostic histopathologic features of ocular malaria.Ophthalmology. 1993;100:1183-6. • Lewallen et al. Clinical-histopathological correlation of the abnormal retinal vessels in cerebral malaria. Arch Ophthalmol. 2000 ;118:924-8. • BeareNA et al. Malarial retinopathy: a newly established diagnostic sign in severe malaria.Am J Trop Med Hyg. 2006;75:790-7.

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