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

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

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

First Examination - Fundus

Fluorescein Angiography EarlyMiddle Late  delayed arterio-venous filling,  marked hypofluorescence secondary to capillary non-perfusion  retinal hemorrhages and late staining of the disc

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

Diagnosis Combined CRVO & CRAO with malaria

Treatment  Oral & topical corticosteroids  Oral antimalarial ( Tab Falcigo)  Panretinal photocoagulation

Follow up after 2 months  BCVA CF 50cms  Fundus Vitreous hemorrhage  Treatment Transscleral Cryotherapy

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

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

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

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

References Lewallen S. Ocular malaria. Ophthalmology. 1997;104: Lewallen S. Ocular malaria. Ophthalmology. 1997;104: Biswas et al. Ocular malaria. A clinical and histopathologic study. Ophthalmology Sep;103: Biswas et al. Ocular malaria. A clinical and histopathologic study. Ophthalmology Sep;103: Hidayat et al. The diagnostic histopathologic features of ocular malaria.Ophthalmology. 1993;100: Hidayat et al. The diagnostic histopathologic features of ocular malaria.Ophthalmology. 1993;100: Lewallen et al. Clinical-histopathological correlation of the abnormal retinal vessels in cerebral malaria. Arch Ophthalmol ;118: Lewallen et al. Clinical-histopathological correlation of the abnormal retinal vessels in cerebral malaria. Arch Ophthalmol ;118: Beare NA et al. Malarial retinopathy: a newly established diagnostic sign in severe malaria. Am J Trop Med Hyg. 2006;75: Beare NA et al. Malarial retinopathy: a newly established diagnostic sign in severe malaria. Am J Trop Med Hyg. 2006;75:790-7.