Bilateral retinal haemorrhages: an unusual presentation of pernicious anaemia


A 138-year-old Afro-Caribbean man presented with sudden onset of reduced vision in both eyes. In addition, preceding these symptoms, he complained of marked lethargy and burning sensation in the lower limbs. On examination, right visual acuity was 6/12 and left visual acuity was 6/60. Widespread superficial and premacular haemorrhages were present in both fundi. Fluorescein angiography confirmed the superficial nature of the retinal haemorrhages, and no neovascularization was identified. Haematological investigations showed Hb 3·2 g/dl, WCC 3·7 × 109 and MCV 97 fl. Blood film showed anisopoikilocytosis, macro-ovalocytes and marked dyserythropoiesis. LDH was markedly elevated at 3164 µ/l. Bone marrow aspirate confirmed megaloblastic anaemia, and haematinic assay showed B12 levels of 59 ng/l, red cell folate 134 μg/l and ferritin 324 μg/l. Gastric and intestinal biopsy did not show evidence of inflammation, neoplasia, parasitic organisms or villous atrophy. A Schilling's test established the diagnosis of pernicious anaemia. His visual acuity and the systemic symptoms improved rapidly with hydroxycobalamin and folic acid supplementation.

Figure 1.