Dear Editor,
A 35-year-old female was referred for complaints of headache and defective vision in her left eye (OS) for the past 10 days. She had a recent history of menorrhagia which lasted for 2 months and was treated with oral tranexamic acid and progesterone. On examination, her visual acuity was 6/6 in both eyes. Her intraocular pressure and color vision were normal. Grade 1 relative afferent pupillary defect was noted in OS. On dilated examination, the left optic disc showed blurred superonasal disc margins [Fig. 1a]. Humphrey visual analyzer 30-2 protocol showed inferior altitudinal field defect in OS [Fig. 1b]. The right eye was normal. Blood investigations showed hemoglobin (Hb) 7 g/dl and peripheral smear showed microcytic hypochromic red blood cells. Other parameters were normal. A diagnosis of non-arteritic anterior ischemic optic neuropathy (NAION) secondary to anemia following menorrhagia was made. She was referred to the gynecologist for further management. Three months later, left eye disc edema subsided with minimal disc pallor but persisting field defects [Fig 1c and f]. Her Hb had improved to 12 g/dl.
Figure 1.
Normal optic disc in the right eye. (a) Component a shows normal disc in right eye. (b) shows blurring of superior disc margin in the left eye.(c) shows the resolution of the blurring of the disc margins in the left eye post-correction of anemia. (d) shows normal fields with few absolute defects in the right eye in Humphrey visual analyzer 30-2 protocol. (e) shows inferior altitudinal field defects in the left eye. (f) shows the resolution of inferior altitudinal field defects in the Humphrey visual analyzer 30-2 protocol
NAION results from an ischemic insult to the optic nerve head and is characterized by acute unilateral painless vision loss and disc swelling. It is known to occur in younger individuals who have a vasculopathy risk factor.[1] Headache and periocular pain is reported in 8–12% of the patients.[2] In our patient, acute anemia due to prolonged menorrhagia led to ischemic optic neuropathy. There is evidence that with profound anemia there is a hypoxic insult to the optic disc due and microvascular insufficiency when metabolic stress could not be met.[3]
Hence, the importance of ophthalmic evaluation in patients with severe blood loss and anemia should not be undermined. A regular ophthalmic referral should be encouraged even if they have no significant vision loss for early detection.
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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.
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References
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