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Year : 2022  |  Volume : 10  |  Issue : 3  |  Page : 131-133

Retinal hemorrhage and internal limiting membrane detachment in Plasmodium vivax infection: A case report

1 Department of Ophthalmology, Armed Forces Clinic, Armed Hospital R and R, New Delhi, India
2 Department of Ophthalmology, Armed Hospital R and R, New Delhi, India
3 Department of Ophthalmology, Army Base Hospital, New Delhi, India
4 Department of Ophthalmology, Command Hospital, Pune, Maharashtra, India

Date of Submission20-Mar-2022
Date of Decision13-Jul-2022
Date of Acceptance26-Aug-2022
Date of Web Publication1-Dec-2022

Correspondence Address:
Mohini Agrawal
Department of Ophthalmology, Command Hospital, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcor.jcor_47_22

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Retinal hemorrhage is common in Plasmodium falciparum and has been seldom reported with Plasmodium vivax. A 13-year-old girl presented with vision loss in both eyes after 1 week of intravenous artemisinin-based combination treatment for P. vivax. The patient had bilateral vision of 1/60 with retinal hemorrhage and internal limiting membrane (ILM) detachment. In view of heme-toxicity, the patient underwent an intravitreal tissue plasminogen activator along with 100% sulfur hexafluoride. Following this, hemorrhage resolved and vision improved to 6/9. Thus, although rare, retinal hemorrhage and ILM detachment can also be seen with P. vivax, albeit more common in P. falciparum.

Keywords: Malarial retinopathy, Plasmodium vivax, retinal hemorrhage

How to cite this article:
Vats S, Mishra S, Kumar P, Jhanwar M, Agrawal M. Retinal hemorrhage and internal limiting membrane detachment in Plasmodium vivax infection: A case report. J Clin Ophthalmol Res 2022;10:131-3

How to cite this URL:
Vats S, Mishra S, Kumar P, Jhanwar M, Agrawal M. Retinal hemorrhage and internal limiting membrane detachment in Plasmodium vivax infection: A case report. J Clin Ophthalmol Res [serial online] 2022 [cited 2023 Jan 31];10:131-3. Available from: https://www.jcor.in/text.asp?2022/10/3/131/362505

Ocular manifestations in malaria include vitreous hemorrhage, subhyaloid bleed, retinal whitening, vascular occlusion, white-centered retinal hemorrhage, soft and hard exudates, papilledema, uveitis, disc pallor or hyperemia, optic neuritis, and cortical blindness.[1],[2] Retinal hemorrhage is common in Plasmodium falciparum and has been rarely reported with Plasmodium vivax.

We report a case of P. vivax infection in a 13-year-old girl who presented with vision loss in both eyes and was found to have retinal hemorrhage and internal limiting membrane (ILM) detachment in both eyes. She was successfully managed with an intravitreal recombinant-tissue plasminogen activator (t-PA) along with 0.6 ml of 100% sulfur hexafluoride (SF6) to prevent visual morbidity.

  Case Report Top

A 13-year-old female presented with sudden-onset painless diminution of vision in both eyes of 24 h duration. She had high-grade fever for the past 1 week associated with chills and rigors. There was no history of altered sensorium or seizures. There were no signs of meningeal irritation and systemic examination revealed no abnormality. On investigations, she had anemia (Hb = 8 g/dl) and thrombocytopenia (90,000 platelets per microliter). Her peripheral blood smear showed trophozoite ring forms of P. vivax. She was managed with intravenous artemisinin-based combination treatment (ACT). Dengue NS1 antigen and P. falciparum rapid antigen test were negative. After 1 week of treatment, she presented with headache and sudden vision loss in both eyes. Best-corrected visual acuity was 1/60 in both eyes. Anterior segment examination and intraocular pressure were normal. Fundus examination showed large superficial, blotchy, peripapillary, and premacular boat-shaped hemorrhages in both eyes as depicted in [Figure 1]a and [Figure 1]b. There were few intraretinal hemorrhages also with central whitening (Roth spots) in the periphery [Figure 2]a. No other abnormality like cotton-wool spots, papilledema, or vasculitis was found. Fundus fluorescein angiography showed blocked fluorescence in both eyes. Optical coherence tomography (OCT) macula confirmed the location of intraretinal hemorrhage and showed ILM detachment [Figure 2]b.
Figure 1: Preoperative fundus photographs of the right (a) and left eye (b) showing preretinal hemorrhages in a case of Plasmodium vivax infection

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Figure 2: (a) Fundus photograph showing intraretinal hemorrhages with central whitening in the periphery in the right eye; (b) preoperative optical coherence tomography revealing extensive subinternal limiting membrane fluid with detachment

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Given bilateral severe vision loss and possibility of heme-toxicity to the macula, she underwent intravitreal recombinant-t-PA (alteplase™ 25 μg in 0.05 ml) along with 0.6 ml of 100% SF6 in both eyes. She was advised of strict prone positioning postoperatively. On follow-up, vision improved to 6/18 in 3 days with substantial reduction in size of hemorrhages as shown in [Figure 3]. Two weeks after the treatment, the vision recovered to 6/9 in both eyes with an improved OCT picture as shown in [Figure 4]a and [Figure 4]b. Isolated residual visual-field defects were seen on central 10° perimetry in both eyes.
Figure 3: Postoperative fundus photograph of the right (a) and left eye (b) showing resolution of retinal hemorrhages after treatment with intravitreal tissue plasminogen activator and sulfur hexafluoride

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Figure 4: Postoperative optical coherence tomography of the right eye (a) and left eye (b) showing resolution of subinternal limiting membrane fluid at 2 weeks after treatment with intravitreal tissue plasminogen activator and sulfur hexafluoride

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  Discussion Top

Among all species of Plasmodium genus causing malaria, P. falciparum and P. vivax are very significant. P. falciparum malaria is most common; however, P. vivax has a broader distribution worldwide. Severe malaria may present with impaired consciousness, seizures, circulatory shock, renal dysfunction, respiratory discomfort, pulmonary edema, and death.[3] Malarial death depends upon the severity of the disease, the occurrence of cerebral malaria, and the severity of malarial retinopathy.[1] It is characterized by features such as retinal whitening, retinal hemorrhages, vasculitis, cotton-wool spots, and papilledema, which have been primarily described in patients suffering from cerebral malaria due to P. falciparum.

However, there are only limited case reports that account for retinopathy in vivax malaria.[2],[4],[5],[6] To the best of our knowledge, ours is the one study that describes noncerebral malarial retinopathy in P. vivax infection occurring at young age and the first report on ILM detachment in this infection.

In this case, the patient presented with ocular signs and symptoms after 1 week of treatment for malaria. Her vision dropped drastically to 1/60 and had extensive preretinal hemorrhages which required intervention to prevent further visual disability. Retinal histology suggests that the vascular findings are due to sequestration of dehemoglobinized erythrocytes.[7] This is pathognomonic in P. falciparum patients. However, the cause and mechanism of the same in P. vivax infection are not clear. Accompanied anemia and thrombocytopenia, as seen in our case, may have a role in the development of retinal hemorrhages; however, inconclusive studies are there regarding the same.[8]

Majority of these cases have been reported largely from India or South Korea.[2],[5],[6] All the reported cases had retinal hemorrhages, and few had subhyaloid hemorrhages in addition.[2],[5],[6],[9] In all these cases, there was spontaneous resolution of the hemorrhages and good functional recovery of vision. Our case expands the existing literature on retinal hemorrhage in P. vivax infection. Endemic prevalence might be associated with it, but it needs further studies to support the same Thus, the possibility of retinal hemorrhages should be considered even in P. vivax infection. Hence, every patient should be screened by fundus examination for retinal hemorrhages in malaria. Other notable findings such as vasculitis, cotton-wool spots, papilledema, and vascular changes were not seen. However, cotton-wool spot has been reported in a case of P. vivax.[6]

Our patient gave consent for intravitreal injection and gas procedure only after explaining all the modalities of treatment. Spontaneous reabsorption of blood in subhyaloid space is usually slow and takes months to years to resolve. Cataract, epiretinal membrane, macular traction, and retinal detachment can be a sequel of prolonged malarial retinopathy. The longstanding hemorrhage may lead to permanent retinal damage causing permanent visual loss. Observation and vitrectomy were the options available in the earlier days. Intravitreal t-PA with the introduction of expansile gases is now another possibility for faster hemorrhage resolution, hence avoiding the complications of vitrectomy. Hyaloidotomy or membranectomy using different lasers such as Nd: YAG laser (1064 nm) or argon laser (514 nm) are other alternate methods.[10]

  Conclusion Top

This case concludes that P. vivax malaria can present with extensive retinal hemorrhages and ILM detachment, though more common in P. falciparum. Hence, the possibility of retinal hemorrhages should be kept in mind and screening to be considered in patients with P. vivax infection as well.

Declaration of the patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands 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

Harding SP, Lewallen S, Beare NA, Smith A, Taylor TE, Molyneux ME. Classifying and grading retinal signs in severe malaria. Trop Doct 2006;36 Suppl 1:1-13.  Back to cited text no. 1
Biswas J, Fogla R, Srinivasan P, Narayan S, Haranath K, Badrinath V. Ocular malaria. A clinical and histopathologic study. Ophthalmology 1996;103:1471-5.  Back to cited text no. 2
World Health Organization. Guidelines for the treatment of malaria. World Health Organization; 2015.  Back to cited text no. 3
Choi HJ, Lee SY, Yang H, Bang JK. Retinal haemorrhage in vivax malaria. Trans R Soc Trop Med Hyg 2004;98:387-9.  Back to cited text no. 4
Lee JH, Chin HS, Chung MH, Moon YS. Retinal hemorrhage in Plasmodium vivax malaria. Am J Trop Med Hyg 2010;82:219-22.  Back to cited text no. 5
Kochar A, Kalra P, Kochar S, Kochar SK, Kochar DK. Retinal haemorrhage: An unusual presentation of vivax malaria. J Vector Borne Dis 2013;50:321-2.  Back to cited text no. 6
[PUBMED]  [Full text]  
Lewallen S, White VA, Whitten RO, Gardiner J, Hoar B, Lindley J, et al. Clinical-histopathological correlation of the abnormal retinal vessels in cerebral malaria. Arch Ophthalmol 2000;118:924-8.  Back to cited text no. 7
Incorvaia C, Parmeggiani F, Costagliola C, Perri P, D'Angelo S, Sebastiani A. Quantitative evaluation of the retinal venous tortuosity in chronic anaemic patients affected by beta-thalassaemia major. Eye (Lond) 2003;17:324-9.  Back to cited text no. 8
Sharma S, Maheshwari U, Bansal N. Retinal haemorrhage in Plasmodium vivax patients-2 rare case reports. J Evol Med Dent Sci 2012;1:929-31.  Back to cited text no. 9
Celebi S, Kükner AS. Photodisruptive Nd: YAG laser in the management of premacular subhyaloid hemorrhage. Eur J Ophthalmol 2001;11:281-6.  Back to cited text no. 10


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


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