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Combined CRVO & CRAO

Combined CRVO & CRAO. Mamta Agarwal Senior Consultant Uveitis & Cornea Services Sankara Nethralaya Chennai. 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,

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Combined CRVO & CRAO

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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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