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Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 193-196

Nutritional anemia as a cause of reversible blindness

Department of General Medicine, KMC, Kurnool, Andhra Pradesh, IndiaDepartment of General Medicine, KMC, Kurnool, Andhra Pradesh, India

Date of Submission27-Nov-2019
Date of Decision28-Jul-2020
Date of Acceptance24-Aug-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Damam Srinivasulu
Assistant Professor, Department of General Medicine, KMC, Kurnool, H-no 80/120 - B - 3, Abbas Nagar , Kallur post , Kurnool 518002, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None


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We report a case of 42-year-old male presented with acute onset breathlessness and blurring of vision in both eyes. Upon evaluation, the patient is found to have vitamin B12 and iron deficiency anemia; ophthalmoscopic examination revealed bilateral preretinal hemorrhages and Roth spots. This case documents the occurrence of retinopathy in nutritional dimorphic anemia causing blindness which is reversible after correction of anemia.

Keywords: Anemic retinopathy, B12 Deficiency, pancytopenia, Roth spots

How to cite this article:
Ranganath M, Srinivasulu D, Poornima K, Anusha V. Nutritional anemia as a cause of reversible blindness. J NTR Univ Health Sci 2020;9:193-6

How to cite this URL:
Ranganath M, Srinivasulu D, Poornima K, Anusha V. Nutritional anemia as a cause of reversible blindness. J NTR Univ Health Sci [serial online] 2020 [cited 2020 Nov 26];9:193-6. Available from: https://www.jdrntruhs.org/text.asp?2020/9/3/193/296823

  Introduction Top

Nutritional anemia is a common hematological condition encountered in daily clinical practice. Inadequate dietary intake of vitamin B12 and iron is the most common cause of dimorphic anemia.[1] It can present as bicytopenia, i.e., decrease in two cell lines or pancytopenia, defined as a decrease in all the three cell lines of blood, viz., red blood cells, leucocytes, and platelets.

It has varied presentations depending upon its etiology and severity.

These features include easy fatigability, epistaxis, hyperpigmentation, glossitis, susceptibility to infections, and even congestive cardiac failure. Ocular manifestations are a rarity and so far described are optic atrophy in vitamin B12 deficiency seen in 1% of cases.

Retinopathy secondary to anemia or pancytopenia is asymptomatic in most of the cases. We report a rare case of nutritional anemia presented with visual disturbances due to macular hemorrhages and showed rapid improvement with supplementation of vit B12 and iron.

  Case History Top

A 42-year-old male presented to Department of General Medicine, Government General Hospital, Kurnool with complaints of breathlessness on exertion since 1 week. There is no history of cough, chest pain, and palpitations. He also had complaints of decreased vision in both eyes since 5 days, which was sudden in onset, not progressive, not associated with pain. Patient is chronic alcoholic since 10 years, not a smoker, diabetic or hypertensive.

On examination, pallor and icterus are present; pulse rate-102 beats per min, high volume.

Blood pressure was normal.

Cardiovascular, respiratory, and gastrointestinal system were normal. Neurological examination was normal except for absent ankle reflex.

  • Visual acuity in both eyes: counting fingers at 5 m.
  • Intraocular pressure in both eyes was 17.5 mmHg.

Detailed ocular examination revealed mild blurring of disc margins in left eye, background retina in both eyes showing preretinal hemorrhages, and Roth spots [Figure 1] macula showing boat-shaped preretinal hemorrhages [Figure 2].
Figure 1: Roth spots

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Figure 2: Boat-shaped macular hemorrhage

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Possibility of hemorrhagic retinopathy secondary to severe anemia and thrombocytopenia was thought and patient was investigated to know the cause of pancytopenia [Table 1].
Table 1: Complete Hemogram

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Peripheral smear showed a severe degree of microcytic hypochromic along with macrocytic normochromic cells with leucopoenia and thrombocytopenia suggesting dimorphic anemia. Corrected reticulocyte count-0.2%, reticulocyte production index-0.1

Serum bilirubin-2.9 mg/dL, indirect bilirubin-2.0 mg/dL, liver enzymes-normal, serum LDH-250 IU/L.

Bleeding time: 3 minutes 15 seconds, clotting time: 5 minutes 30 seconds.

Prothrombin time-8 s, INR-1.6, activated partial thromboplastin time-46 s.

Renal function tests-normal

Viral screening was nonreactive.

Ultrasound abdomen-hepatomegaly 16 cm.

Upper gastrointestinal endoscopy revealed findings suggestive of hemorrhagic gastropathy.

A diagnosis of nutritional dimorphic anemia with vitamin B12 and iron deficiency secondary to chronic alcoholism was made [Table 2].
Table 2: Anemia Profile

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He was transfused with 1 unit fresh whole blood and later hydroxycobalamin injections daily intramuscularly for 1 week, then weekly for 1 month along with iron and folic acid supplementation.

After 4 weeks, hemoglobin improved to 8.9 g/dL, platelet count 3.23 lakhs/mL. Visual acuity improved in left eye to 6/24, right eye to 6/36.

After 2 months, there is complete resolution of hemorrhages in both eyes and visual acuity improved to 6/9 in both eyes.

Hemorrhages in retina resolved spontaneously [Figure 3] and [Figure 4].
Figure 3: Right eye fundus picture after 2 months

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Figure 4: Left eye fundus picture after 2 months

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  Discussion Top

Anemia causes retinopathy in 20%–30% of cases. If coexisting thrombocytopenia is present, then incidence of retinopathy is increased to 30%–40%. Isolated thrombocytopenia as seen in dengue fever and systemic infections can result in retinal changes in 10%–20% patients.

Risk of retinopathy increases with severity of anemia and thrombocytopenia, i.e., if hemoglobin <6 g/dL[2] and platelet count <50,000 cells/mL.[3]

Retinal changes in anemia are superficial flame-shaped hemorrhages in nerve fiber layer which are commonly seen.[4] Others including preretinal hemorrhages occurring in subhyaloid plane, dot and blot hemorrhages in deeper layers may be noted. These hemorrhages were first described by Ulrich in 1883 in association with gastrointestinal hemorrhage.[5]

Roth spots can be seen. They are white-centered retinal hemorrhages. White center in hemorrhages represents focal ischemia, inflammatory infiltrates, fibrin and platelets, and accumulation of neoplastic cells.

Retinal arteries are attenuated and pale, veins are dilated and tortuous.

The pathophysiology for these changes is retinal hypoxia due to anemia leading to dilatation of veins and increasing capillary fragility and eventually hemorrhages in retinal layers.[6]

This type of retinopathy was described in several conditions like pernicious anemia, iron deficiency anemia, sickle cell anemia, and aplastic anemia.

Vitamin B12 deficiency is associated with increased risk of retinal hemorrhages because of coexisting anemia and thrombocytopenia.

Optic atrophy in vitamin B12 deficiency is very rare and is seen in less than 1% of cases.[7]

Anemic retinopathy is usually asymptomatic and does not require any specific treatment. The underlying cause for anemia is to be investigated and correction of anemia will resolve the retinal changes. Dramatic response occurs with the resolution of ocular hemorrhages after vitamin B12 supplementation.

Intervention in these cases is rarely needed if the preretinal subhyaloid hemorrhages involve the macular region causing visual symptoms. These patients undergo posterior hyaloidotomy using ND YAG laser which enables the drainage of entrapped blood into vitreous humor.

The purpose of this report is to highlight the importance of nutritional anemia secondary to vitamin B12 and iron deficiency as a cause of potentially reversible blindness due to anemic retinopathy.

Key Messages

: An unusual case of anemic retinopathy causing blindness is potentially reversible with treatment of anemia. Roth spots, although traditionally thought to be associated with infective endocarditis can occur in other conditions like pernicious anemia, leukemia, carbon monoxide poisoning, HIV retinopathy, hypertensive, and diabetic retinopathy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kasper DL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, 20th ed. New York: McGraw-Hill Medical;2015.  Back to cited text no. 1
Carraro MC, Rosetti L, Gerli GC. Prevalence of retinopathy in patients with anaemia or thrombocytopenia. Eur J Haematol 2001.  Back to cited text no. 2
Rubenstein RA, Yanoff M, Albert DM. Thrombocytopenia, anemia and retinal hemorrhage Am J Ophthalmol 1968.  Back to cited text no. 3
Vidya H, Neelam P, Anupama B, Sowmya PD. Subhyaloid hemorrhage in severe dimorphic anmeia and thrombocytopaenia – a case report. Journal Of Clinical and Diagnostic Research [Serial Online]. 2010;4:3201-2.  Back to cited text no. 4
Pears MA, Pickering GW. Changes in the fundus oculi after hemorrhage. Q J Med 1960;29:153-78.  Back to cited text no. 5
Beck RW, Smith CH. Neuro-opthalmology: Problem oriented approach. Boston: Little, Brown, and CO;1988.  Back to cited text no. 6
Lennihan L, Rowland LP. Nutritional disorders malnutrition, malabsorption and B12 and other vitamin deficiency. In: Merritt's Neurology 12th Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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