|
 
 |
| CASE REPORT |
|
| Year : 2022 | Volume
: 60
| Issue : 4 | Page : 315-317 |
|
Self-harm induced bilateral CRVO
K Rajasekar, M Sangamithira, G Sathya
Vitreo-Retina Department, Regional Institute of Ophthalmology and Govt. Ophthalmic Hospital (RIOGOH), Chennai, Tamil Nadu, India
| Date of Submission | 05-Jan-2022 |
| Date of Decision | 28-Jul-2022 |
| Date of Acceptance | 15-Aug-2022 |
| Date of Web Publication | 19-Dec-2022 |
Correspondence Address:
M Sangamithira
Regional Institute of Ophthalmology and Govt. Ophthalmic Hospital (RIOGOH), Chennai, Tamil Nadu - 600 008
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjosr.tjosr_2_22
Central retinal vein occlusion (CRVO) is a common diagnosis encountered in our clinic. Patients usually have predisposing factors and regular presentation but, in this paper, we present an extremely unusual incidence of bilateral CRVO in a young male. The patient had jumped from the second floor after consumption of poison and suffered bilateral pneumothorax that needed hospitalisation for 5 weeks. Though the patient had noticed blurring in both eyes, he presumed it to his myopic state and broken glasses. On reporting to us after 2 months of this misfortune, he had non-ischemic variant of bilateral CRVO with Cystoid macular edema (CME) as consequences of bilateral pneumothorax. He was treated with single dose of inj. Avastin and macular grid laser in both eyes. Patient responded well and his visual status improved and now he is in follow-up. This case is being presented for its rarity and unusual profile.
Keywords: Anti-VEGF, bilateral CRVO, bilateral pneumothorax
How to cite this article:
Rajasekar K, Sangamithira M, Sathya G. Self-harm induced bilateral CRVO. TNOA J Ophthalmic Sci Res 2022;60:315-7 |
| Introduction | |  |
Central retinal vein occlusion (CRVO) usually occurs above the age of 50 years causing visual impairment. The condition typically befalls unilateral and very rarely (around 5% cases) we see bilateral presentation. Affected individuals might have underlying systemic disease like hypertension, diabetes, dyslipidaemia or hypercoagulable states. Here we present a case of bilateral CRVO in a young male due to bilateral pneumothorax following a suicidal attempt. We think that it is the rarest of rare cause as a similar condition had been reported in literature only once.
| Case Report | | |
A 32-year-old male attended retina department with complaints of defective vision in both eyes for 2 months with a history of suicide attempt 2 months ago with mosquito killer poisoning and then surviving a fall from the second floor. He sustained bilateral ribs fracture and developed bilateral pneumothorax and haemothorax. Intercostal tube drainage was placed bilaterally on the same day, needing hospitalisation for 1 month. Newly detected diabetes mellitus—2 month ago on oral hypoglycaemic drugs.
His best-corrected visual acuity (BCVA) in both eyes was 6/18. Intraocular pressure measured using Goldmann tonometer was right eye (RE) – 17 mmHg and left eye (LE) – 18 mmHg. On slit-lamp examination, anterior segment was normal. Fundus examination using indirect ophthalmoscope showed both eyes media clear, disc hyperaemia with disc oedema in the right eye, superficial haemorrhage seen in all quadrants with macular oedema suggestive of bilateral CRVO as shown in [Figure 1]. Fundus fluorescein angiography showed delayed filling of veins in the early stage with diffuse leakage around the vessels and staining of disc noted in late stage as shown in [Figure 2]. Optical coherence tomography (OCT) showed central foveal thickness of more than 1000 μm in the right eye and 741 μm in the left eye. Occlusion workup was done for the patient. Blood investigations like fasting blood sugar (FBS) – 101 mg/dL, postprandial blood sugar (PPBS) – 130 mg/dL, haemoglobin A1c (HbA1C) – 6, Hb – 1 1 g/dL urea – 25 mg/dL, creatinine – 0.8 mg/dL, serum homocysteine levels – 12 m μmol/L, triglycerides (TGL) – 160 mg/dL, low-density lipoprotein (LDL) – 90 mg/dL, high-density lipoprotein (HDL) – 40 mg/dL, bleeding time (BT) – 3 min and computed tomography (CT) –8 min were within normal limits. Investigations to rule out inflammation like erythrocyte sedimentation rate (ESR) –5 mm/h, C-reactive protein (CRP) –1 mg/L were within the normal limits. Cardiac echocardiogram (ECHO) and carotid Doppler were also normal. | Figure 1: Fundus picture of Right eye (a) and Left eye (b) in bilateral CRVO
Click here to view |
 | Figure 2: Fundus fluorescein angiography picture of Right eye (a) and Left eye (b) in bilateral CRVO
Click here to view |
He was diagnosed as bilateral non-ischemic CRVO with CME. We hypothesize that the probable pathogenesis in this patient had been in venous stagnation due to bilateral pneumothorax[1] and immobilisation as explained in [Figure 3]. It lead to a temporary hypercoagulable state which lead to bilateral CRVO.
After comprehensive workup and monitored anaesthetic care, we treated both eyes with single dose of intravitreal injection bevacizumab 1.25 mg/0.05 mL given 1 week apart. Two weeks later, both eye macular grid laser with 532 nm green laser was done. Patient was kept on Nepafenac eye drops three times daily for both eyes for a period of 3 months.
His best-corrected visual acuity was improving to 6/9 in both eyes. Fundus examination using indirect ophthalmoscope showed both eyes media clear, resolving superficial haemorrhages and disc oedema, hard exudate in and around macula as shown in [Figure 4]. Central foveal thickness in OCT improved to RE – 228 μm and LE – 222 μm as shown in [Figure 5]. | Figure 4: Fundus picture of Right eye (a) and Left eye (b) in bilateral CRVO after intravitreal Bevacizumab injection
Click here to view |
 | Figure 5: CFT during different stages of treatment of macular edema in B/L CRVO
Click here to view |
| Discussion | | |
CRVO most commonly occurs in the elderly people. Incidence of CRVO in young individual is always suspicious where systemic causes should be assessed meticulously. These include systemic lupus erythematosus (SLE),[2] antiphospholipid antibody syndrome (APS),[3] hyper viscosity syndrome,[4] hyperhomocysteinemia,[5] dysproteinaemia and leukaemia with thrombocytopenia.[6] This article cites only one published report of bilateral CRVO due to diaphragmatic eventration.[1] It states that diaphragmatic eventration has caused respiratory failure with secondary polyglobulia, in addition impaired venous drainage due to increased intrathoracic pressure which ultimately led to venous stagnation and retinal vein thrombosis. Likewise in our case, the patient sustained bilateral pneumothorax and haemothorax which in turn lead to increased intrathoracic pressure. Increased intrathoracic pressure had impaired the venous drainage which eventually directed to venous stagnation, thrombus formation and bilateral CRVO consecutively.
| Conclusion | | |
Bilateral CRVO is uncommon in young individuals. When a CRVO is observed in a young patient, thorough history should be sought with high index of suspicion for more obscure underlying aetiologies. Here, in this case, a detailed history has revealed the basis for CRVO, which is due to an uncommon cause. We could manage the case effectively with intravitreal injection and macular grid, which improved the visual acuity. Patient improved well and was kept in regular follow-up and also on psychological counselling. He is back to his normal routine.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given her consent for images and other clinical information to be reported in the journal. The guardian understands that her names and initials will not be published and due efforts will be made to conceal the patient's identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Ster A-M, Stan C, Ghervan M. Bilateral central vein occlusion in a case of diaphragmatic eventration. Maedica (Bucur) 2014;9:278-81.  |
| 2. | Akhlaghi M, Abtahi-Naeini B, Pourazizi M. Acute vision loss in systemic lupus erythematosus: Bilateral combined retinal artery and vein occlusion as a catastrophic form of clinical flare. Lupus 2018;27:1023-6. |
| 3. | Tomasini DN, Segu B. Systemic considerations in bilateral central retinal vein occlusion. Optometry 2007;78:402-8. |
| 4. | Golesic EA, Sheidow TG. An otherwise healthy young man presents with bilateral CRVO as the first sign of hyperviscosity syndrome in the setting of new multiple myeloma. Retin Cases Brief Rep 2015;9:38-40. |
| 5. | Gelman R, DiMango EA, Schiff WM. Sequential bilateral central retinal vein occlusions in a cystic fibrosis patient with hyperhomocysteinemia and hypergamma-globulinemia. Retin Cases Brief Rep 2013;7:362-7. |
| 6. | Uhr JH, Thau A, Chung C, Zhang XC. Rare presentation of bilateral central retinal vein occlusion and leukemic retinopathy in a young adult diagnosed with T-cell acute lymphoblastic leukemia. Cureus 2020;12:e6666. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
|
Search Pubmed for