Bilateral Macula-Involving Subhyaloid and Peripapillary Haemorrhages in Severe Pancytopenia with Transient Visual Loss and Recovery on Observation: A Case Report

Background: Retinal haemorrhage is a recognised ocular manifestation of bone marrow failure, but bilateral macula-involving subhyaloid haemorrhage and its visual course are rarely documented with serial fundus photography. Case presentation: A 37-year-old male presented with blurred vision in both eyes for 10 days. An outside hospital had found multiple retinal haemorrhages and pancytopenia, and he was admitted for evaluation of the pancytopenia. At presentation, visual acuity was 6/9 in the right eye and 6/6p in the left eye, near vision was N6 in both eyes, and intraocular pressures were 15 and 16 mmHg. Fundus examination showed bilateral boat-shaped macular subhyaloid haemorrhages, dense haemorrhages along the superotemporal arcade adjacent to the optic disc, and scattered intraretinal haemorrhages. Haemoglobin was 8.0 g/dL, platelet count 15 × 10³/µL, white cell count 2.7 × 10³/µL (calculated absolute neutrophil count ≈0.62 × 10³/µL) and absolute reticulocyte count 15.6 × 10³/µL, with erythropoietin 326.8 mIU/mL; PT/INR was normal. He was treated with eltrombopag, tranexamic acid and cyclosporin. Visual acuity then fell to 6/60 in the right eye and 6/24 in the left eye as the haemorrhage involved the fovea. Nd:YAG laser hyaloidotomy was considered, but because blood counts remained low he was observed closely. On serial examination the haemorrhages contracted progressively and cleared from the macula, and visual acuity recovered to 6/6 in both eyes. Conclusion: Severe pancytopenia can produce bilateral macular subhyaloid haemorrhage with transient, marked visual loss when the fovea is involved. Even so, close observation without hyaloidotomy, while blood counts remained low, was followed by spontaneous resolution and full visual recovery. A dilated fundus examination should form part of the work-up of severe cytopenia, and retinal intervention should be approached conservatively while thrombocytopenia persists.