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Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 992-993

The triad of concentric premacular hemorrhages, Roth spots, and koilonychia


Department of Vitreo Retina, Netralaya Superspeciality Eye Hospital, Ahmedabad, Gujarat, India

Date of Submission11-Jun-2022
Date of Acceptance28-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Kushal Delhiwala
Department of Vitreo Retina Netralaya Superspeciality Eye Hospital, KD House, 1st Floor, Above Union Bank of India, Parimal Cross Roads, Ellisbridge, Ahmedabad - 380 006, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1405_22

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  Abstract 


Keywords: Anemic retinopathy, iron deficiency anemia, koilonychia, premacular hemorrhage, Roth spots


How to cite this article:
Delhiwala K, Patel R, Khamar B. The triad of concentric premacular hemorrhages, Roth spots, and koilonychia. Indian J Ophthalmol Case Rep 2022;2:992-3

How to cite this URL:
Delhiwala K, Patel R, Khamar B. The triad of concentric premacular hemorrhages, Roth spots, and koilonychia. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Dec 3];2:992-3. Available from: https://www.ijoreports.in/text.asp?2022/2/4/992/358152



A 42-year-old male complaining of sudden-onset diminished vision in the right eye (OD) for 3 days with best-corrected visual acuity of 20/80 and 20/20 in OD and left eye (OS), respectively, had pale conjunctiva bilaterally. Fundus examination revealed venous tortuosity, blot retinal hemorrhages, and Roth spots bilaterally, and a concentric small prefoveal hemorrhage within a large boat-shaped premacular hemorrhage in OD [Figure 1]a,[Figure 1]b,[Figure 1]c. Optical coherence tomography (OCT) macular scans in OD revealed dome-shaped hyperreflective internal limiting membrane (ILM) detachment, hyporeflective sub-ILM cavity corresponding to fluid level, and hyperreflective OCT areas corresponding to premacular hemorrhages causing posterior shadowing [Figure 1]d. Macula was normal in OS.
Figure 1: (a and b) Pseudocolor fundus photos of the right and left eye, respectively, showing venous tortuosity, blot retinal hemorrhages, and Roth spots (black arrows). (c) True color fundus photo of the right eye macula showing concentric large boat-shaped premacular hemorrhage and a small pale prefoveal hemorrhage. (d) Optical coherence tomography macular scan of the right eye showing hyperreflective dome-shaped internal limiting membrane (ILM) detachment, hyporeflective sub-ILM fluid cavity, and hyperreflective OCT areas corresponding to premacular hemorrhages causing posterior shadowing. (e) Koilonychia and pale nail beds

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Patient's history was negative for systemic disease, preceding trauma, or high-altitudinal travel. However, inspection revealed concave nails (koilonychia) and pale nail beds [Figure 1]e. These findings pointed toward a possible underlying iron-deficiency anemia (IDA), which was further favored with hemogram showing hemoglobin: 7 g/dL (normal: 13–17 g/dL), hematocrit: 31.2% (normal: 40%–50%), MCH: 6.2 pg (normal: 27–32 pg), and microcytic hypochromic RBCs with anisopoikilocytosis on peripheral smear.

Anemic retinopathy was managed conservatively and the patient was referred to a physician for management of IDA.


  Discussion Top


Premacular hemorrhage with Roth spots has been reported in aplastic anemia, megaloblastic anemia, leukemia, bacterial endocarditis, and high altitude retinopathy.[1],[2],[3] Koilonychia is primarily recognized as a manifestation of IDA, other causes being trauma, high-altitude, hereditary, and idiopathic.[4]

Presence of premacular hemorrhages, Roth spots, and koilonychia in index cases clinically suggested a higher probability of IDA as underlying etiology due to the negative history of other aforementioned etiologies for them.

Presence of prefoveal hemorrhage within a larger premacular hemorrhage suggests two episodes of hemorrhage, with the larger being recent. Pallor of prefoveal hemorrhage and its irregular borders on OCT may be attributed to absorbing blood clots with condensation of dehemoglobinized RBCs.

To our knowledge, premacular hemorrhage has been reported in IDA.[5] However, concentric small prefoveal hemorrhage within a large premacular hemorrhage alongside Roth spots in IDA has not been previously reported. This case also demonstrates the role of nail examination in cases of premacular hemorrhage with Roth spots.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kanukollu VM, Ahmad SS. Retinal hemorrhage. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.  Back to cited text no. 1
    
2.
Jojo V, Singh P. The eye: A lifesaver! An unusual case of anemic retinopathy secondary to malnutrition and its recovery. J Family Med Prim Care 2020;9:4421-4.  Back to cited text no. 2
  [Full text]  
3.
Mal W, Al-Abri M. Spontaneously resolved severe retinopathy associated with aplastic anemia. Oman J Ophthalmol 2021;14:117-9.  Back to cited text no. 3
  [Full text]  
4.
Rathod DG, Sonthalia S. Spoon nails. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.  Back to cited text no. 4
    
5.
Trivedi BP, Ravindran M, Pawar N, Ramakrishnan R, Shelke V. Iron deficiency anemia presenting with macular star. JAAPOS 2015;19:486-7.  Back to cited text no. 5
    


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