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1
2 Case Report
4 Partial HELLP syndrome with unilateral exudative retinal
5 detachment treated conservativelyQ1
6
7
8 A.V. Pradeep a
Q2 ; Sonali Rao a,⇑
; R. Ramesh Kumar b
Q3
9
10 Abstract
11 Peripartum vision loss, an uncommon, often reversible complication of pregnancy usually occurs in the setting of pre-eclampsia or
12 eclampsia. The HELLP syndrome is characterized by hypertension, elevated liver enzymes and low platelets. This is a rare case of
13 unilateral exudative retinal detachment associated with the Partial HELLP syndrome that occurred after delivery in a 23-year-old
14 Indian womanQ4 . The retinal detachment subsequently reattached with good visual improvement under conservative treatment. This
15 case highlights the importance of early intervention by the ophthalmologist when pregnant women complain about visual
16 symptomsQ5 .
17
18 Keywords: Pre-eclampsia, Exudative retinal detachment, Partial HELLP syndrome
19
20 Ó 2014 Production and hosting by Elsevier B.V. on behalf of Saudi Ophthalmological Society, King Saud University.
21 http://dx.doi.org/10.1016/j.sjopt.2014.03.011
22
23 Introduction
24 Pre-eclampsia is a multisystem disorder and HELLP
25 syndrome is one of its manifestations. HELLP syndrome is
26 defined as the presence of thrombocytopenia (<150,000
27 platelets/microliter), hemolysis and hepatic dysfunction
28 (elevated transaminases and lactate dehydrogenase).1
HELLP
29 syndrome was first described by Weinstein in 1982.2
Partial
30 HELLP syndrome is characterized by one or two of these
31 abnormalities.3
Up to 25% of the patients with pre-eclampsia
32 report visual problems, most common being a decrease in
33 visual acuity. An association between HELLP syndrome and
34 visual problems such as cortical blindness was first described
35 in 1987.4
HELLP syndrome associated case with ophthalmic
36 signs in the form of retinal detachment was first reported
37 by Burke et al.5
Around 18 cases of retinal detachment have
38 been reported so far in the literature in patients with HELLP
39syndrome.1,6–9
Most occur bilaterally during the third trimes-
40ter. Unilateral retinal detachments occurring in the postpar-
41tum period are unusual. Majority of the patients have a
42complete recovery of vision with conservative management
43and surgery is usually unnecessary.10,11
44Case report
45A 23 year old female with Gravida 2 Abortion1 with
4634 weeks of gestation came with a history of pain in the abdo-
47men, headache, low grade fever & high colored urine. Upon
48arrival, her BP was 170/80 mmHg, hemoglobin concentration
4912.7 mg/dl, blood urea 43 mg/dl (range 0–45), creatinine
501.9 mg/dl (range 0.5–1.5), uric acid 12 mg/dl (range 2.4–5.7),
51total bilirubin 6.39 mg/dl (range 0–1.1), direct bilirubin
523.73 mg/dl (range 0–0.30), indirect bilirubin 2.66 mg/dl (range
530.2–0.8), serum aspartate amino transferase (AST) 139 IU/L
Peer review under responsibility
of Saudi Ophthalmological Society,
King Saud University Production and hosting by Elsevier
Access this article online:
www.saudiophthaljournal.com
www.sciencedirect.com
Received 2 July 2013; received in revised form 10 February 2014; accepted 18 March 2014; available online xxxx.
a
Department of Ophthalmology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences, Manjushree Nagar, Sattur,
Dharwad 580009, Karnataka, India
b
Department of Obstetrics and Gynaecology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences, Manjushree Nagar, Sattur,
Dharwad 580009, Karnataka, India
⇑ Corresponding author. Mobile: +91 9986684811.
e-mail addresses: dr.avpradeep@gmail.com (A.V. Pradeep), sonali.rao28@gmail.com (S. Rao), dr_rameshk@rediffmail.com (R. Ramesh Kumar).
Saudi Journal of Ophthalmology (2014) xxx, xxx—xxx
SJOPT 294 No. of Pages 3, Model NS
Please cite this article in press as: Pradeep A.V., et al. Partial HELLP syndrome with unilateral exudative retinal detachment treated conservativelyQ1 . Saudi J
Ophthalmol (2014), http://dx.doi.org/10.1016/j.sjopt.2014.03.011
54 (range 0–46), serum alanine aminotransferase (ALT) 93 IU/L
55 (range 0–49), lactate dehydrogenase 1308 IU/L (range 200–
56 400), platelet count of 1.72 lakhs/cu mm (range 1.5–4) and a
57 blood picture of normocytic normochromia with leukocytosis.
58 She was diagnosed with Partial HELLP syndrome was started
59 on calcium blocker, tablet nifedipine 5 mg twice a day along
60 with alfa blocker, tablet prazocin 5 mg twice a day and subse-
61 quently underwent an emergency cesarean section the follow-
62 ing day for non-reactive Non Stress Test. A single live healthy
63 female baby weighing 2.7 kg was extracted. One month prior,
64 her retinal examination was within normal limits. On post
65 operative day one, her BP was 160/100 mm Hg with total
66 bilirubin of 1.99 mg/dl, direct bilirubin 0.83 mg/dl, indirect
67 bilirubin 1.16 mg/dl, AST 22 IU/L, ALT 26 IU/L, blood urea
68 6.22 mg/dl, and serum creatinine 0.8 mg/dl. On the seventh
69 post-operative day, the patient complained of a sudden onset
70 of blurring of vision in the left eye. On examination her visual
71 acuity in the right eye was 6/6 whereas in the left eye it was
72 6/6 parts. Slit lamp examinations of anterior segment of both
73 eyes were unremarkable with normal IOP. Both eyes’ vitreous
74 was clear. Fundoscopy of the left eye showed dumbbell
75 shaped shallow serous retinal detachment in the inferonasal
76 quadrant extending up to the macula as seen in Fig. 1. Fundus
77fluorescein angiogram in the early phase showed an area of
78delayed choroidal filling. In the midphase, the retinal vascula-
79ture was relatively spared without any evident signs of vascular
80occlusion. In the late venous phase, confluent patches were
81seen indicating choroidal hyper permeability and pooling of
82the dye, which was compatible with the diagnosis of exudative
83retinal detachment seen in Fig. 2. The patient was started on
84an antioxidant tablet, once a day and Nepafenac 0.1% eye
85drops four times per day along with bed rest and head end
86elevation. A diagnosis of severe preeclampsia with Partial
87HELLP syndrome complicated with a unilateral serous retinal
88detachment was made. A week later fundoscopy of the left
89eye revealed resolving serous retinal detachment as seen in
90Fig. 3. One Q6month post treatment the patient showed com-
91plete resolution of the detachment of retina with regaining
92of visual acuity.
93Discussion
94Retinal detachment is an unusual but well documented
95phenomenon in hypertensive disorders of pregnancy affect-
96ing 0.9% of patients with HELLP syndrome.12
Retinal detach-
97ment is seven times more common in women with pre-
98eclampsia or eclampsia with HELLP syndrome than those
99without HELLP syndrome.1
Hutchings et al. suggested that
100retinal detachment is a consequence of choroidal vascular
101damage. Choroidal ischemia is secondary to arteriolar vaso-
102spasm which affects the retinal pigment epithelium and
103breaks down the blood retinal barrier. HELLP syndrome
104causes hemolysis of red blood cells leading to focal ischemia
105due to capillary obstruction.13
Retinal detachment in HELLP
106syndrome is commonly seen in the last trimester of preg-
107nancy, but seldom within the first week postpartum. In the
108postpartum period, subretinal fluid is absorbed by retinal
109pigment epithelium and the visual acuity generally improves
110within weeks.6
In our case, the patient with Partial HELLP syn-
111drome had only unilateral serous retinal detachment as com-
112pared to the bilateral detachments reported in the literature.
113Immediate management of HELLP syndrome and delivery of
114the fetus along with timely intervention by the ophthalmolo-
115gist are advisable to reverse any ocular manifestations and
116avoid long term visual sequelae.7
Figure 1. Fundus photo of the left eye. Fundus photo of the left eye
showing dumbbell shaped shallow retinal detachment inferior to disk
extending up to the macula.
Figure 2. Fluorescein angiogram of the left eye. Left eye fluorescein
angiogram in the late venous phase showing confluent patches indicating
choroidal vasculature hyper permeability and pooling of dye, compatible
with the diagnosis of exudative retinal detachment.
Figure 3. Fundus photo of the same eye one week later. Fundus photo of
the left eye one week later revealed resolving retinal detachment.
2 A.V. Pradeep et al.
SJOPT 294 No. of Pages 3, Model NS
Please cite this article in press as: Pradeep A.V., et al. Partial HELLP syndrome with unilateral exudative retinal detachment treated conservativelyQ1 . Saudi J
Ophthalmol (2014), http://dx.doi.org/10.1016/j.sjopt.2014.03.011
117 Conclusion
118 The case demonstrates that timely intervention and regu-
119 lar follow up visits are essential in pregnant women with pre-
120 eclampsia or eclampsia with HELLP syndrome to avoid visual
121 problems. Hence, all patients with gestational hypertension
122 should undergo a thorough retinal examination.
123 Conflict of interest
124 The authors declared that there is no conflict of interest.
125 References
126 1. Vigil-De Gracia P, Ortega-Paz L. Retinal detachment in association
127 with pre-eclampsia, eclampsia and HELLP syndrome. Int J Gynecol
128 Obstet 2011;114:223–5.
129 2. Burke JP, Whyte I, MacEwen CJ. Bilateral serous retinal detachment
130 in HELLP syndrome. Acta Ophthalmol 1989;67(3):322–4.
131 3. Ian Donald, Hypertensive disorders in pregnancy. In: Renu Misra,
132 editors. Ian Donald’s Practical Obstetric Problems, New Delhi: BI
133 publications pvt ltd; 2008, p. 294.
1344. Levavi H, Neri A, Zoldan J, Segal J, Ovadia J. Pre-eclampsia, ‘‘HELLP’’
135syndrome and postictal cortical blindness. Acta Obstet Gynecol
136Scand 1987;66:91–2.
1375. Jaffe G, Schatz H. Ocular manifestations of preeclampsia. Am J
138Ophthalmol 1987;103:309–15.
1396. Gundlach E, Junker B, Gross N, Hansen LL, Pielen A. Bilateral serous
140retinal detachment. Br J Ophthalmol 2013;97(7):939–40.
1417. Schönfeld C-L. Bilateral Exudative Retinal Detachment in HELLP
142Syndrome. Case Rep Ophthalmol 2012;3(1):35–7.
1438. Lin P, Hahn P, Fekrat S. Peripheral retinal vascular leakage
144demonstrated by ultra-widefield fluorescein angiography in
145preeclampsia with HELLP syndrome. Retina 2012;32(8):1689–90.
1469. Mayer WJ, Hakim I, Ulbig MW, Kernt M, Haritoglou C. Non-mydriatic
147wide field fundus photography in bilateral serous retinal detachment
148due to HELLP syndrome. Arch Gynecol Obstet 2012;286(3):819–20.
14910. Ramaesh K, Nagendran S, Saunders DC. Choroidal ischaemia and
150serous retinal detachment in toxemia of pregnancy. Eye
1511999;13:795–6.
15211. Sathish S, Arnold JJ. Bilateral choroidal ischaemia and serous retinal
153detachment in pre-eclampsia. Clin Exp Ophthalmol 2000;28:387–90.
15412. Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA.
155Maternal morbidity and mortality in 442 pregnancies with hemolysis,
156elevated liver enzymes, and low platelets (HELLP syndrome). Am J
157Obstet Gynecol 1993;169:1000–6.
15813. Hutchings K, Sangalli M, Halliwell T, Tuohy J. Bilateral retinal
159detachment in pregnancy. Aust NZ J Obstet Gynaecol
1602002;42:409–11.
161
Partial HELLP syndrome with unilateral exudative retinal detachmentQ1 3
SJOPT 294 No. of Pages 3, Model NS
Please cite this article in press as: Pradeep A.V., et al. Partial HELLP syndrome with unilateral exudative retinal detachment treated conservativelyQ1 . Saudi J
Ophthalmol (2014), http://dx.doi.org/10.1016/j.sjopt.2014.03.011

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Sd hellp

  • 1. 1 2 Case Report 4 Partial HELLP syndrome with unilateral exudative retinal 5 detachment treated conservativelyQ1 6 7 8 A.V. Pradeep a Q2 ; Sonali Rao a,⇑ ; R. Ramesh Kumar b Q3 9 10 Abstract 11 Peripartum vision loss, an uncommon, often reversible complication of pregnancy usually occurs in the setting of pre-eclampsia or 12 eclampsia. The HELLP syndrome is characterized by hypertension, elevated liver enzymes and low platelets. This is a rare case of 13 unilateral exudative retinal detachment associated with the Partial HELLP syndrome that occurred after delivery in a 23-year-old 14 Indian womanQ4 . The retinal detachment subsequently reattached with good visual improvement under conservative treatment. This 15 case highlights the importance of early intervention by the ophthalmologist when pregnant women complain about visual 16 symptomsQ5 . 17 18 Keywords: Pre-eclampsia, Exudative retinal detachment, Partial HELLP syndrome 19 20 Ó 2014 Production and hosting by Elsevier B.V. on behalf of Saudi Ophthalmological Society, King Saud University. 21 http://dx.doi.org/10.1016/j.sjopt.2014.03.011 22 23 Introduction 24 Pre-eclampsia is a multisystem disorder and HELLP 25 syndrome is one of its manifestations. HELLP syndrome is 26 defined as the presence of thrombocytopenia (<150,000 27 platelets/microliter), hemolysis and hepatic dysfunction 28 (elevated transaminases and lactate dehydrogenase).1 HELLP 29 syndrome was first described by Weinstein in 1982.2 Partial 30 HELLP syndrome is characterized by one or two of these 31 abnormalities.3 Up to 25% of the patients with pre-eclampsia 32 report visual problems, most common being a decrease in 33 visual acuity. An association between HELLP syndrome and 34 visual problems such as cortical blindness was first described 35 in 1987.4 HELLP syndrome associated case with ophthalmic 36 signs in the form of retinal detachment was first reported 37 by Burke et al.5 Around 18 cases of retinal detachment have 38 been reported so far in the literature in patients with HELLP 39syndrome.1,6–9 Most occur bilaterally during the third trimes- 40ter. Unilateral retinal detachments occurring in the postpar- 41tum period are unusual. Majority of the patients have a 42complete recovery of vision with conservative management 43and surgery is usually unnecessary.10,11 44Case report 45A 23 year old female with Gravida 2 Abortion1 with 4634 weeks of gestation came with a history of pain in the abdo- 47men, headache, low grade fever & high colored urine. Upon 48arrival, her BP was 170/80 mmHg, hemoglobin concentration 4912.7 mg/dl, blood urea 43 mg/dl (range 0–45), creatinine 501.9 mg/dl (range 0.5–1.5), uric acid 12 mg/dl (range 2.4–5.7), 51total bilirubin 6.39 mg/dl (range 0–1.1), direct bilirubin 523.73 mg/dl (range 0–0.30), indirect bilirubin 2.66 mg/dl (range 530.2–0.8), serum aspartate amino transferase (AST) 139 IU/L Peer review under responsibility of Saudi Ophthalmological Society, King Saud University Production and hosting by Elsevier Access this article online: www.saudiophthaljournal.com www.sciencedirect.com Received 2 July 2013; received in revised form 10 February 2014; accepted 18 March 2014; available online xxxx. a Department of Ophthalmology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences, Manjushree Nagar, Sattur, Dharwad 580009, Karnataka, India b Department of Obstetrics and Gynaecology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences, Manjushree Nagar, Sattur, Dharwad 580009, Karnataka, India ⇑ Corresponding author. Mobile: +91 9986684811. e-mail addresses: dr.avpradeep@gmail.com (A.V. Pradeep), sonali.rao28@gmail.com (S. Rao), dr_rameshk@rediffmail.com (R. Ramesh Kumar). Saudi Journal of Ophthalmology (2014) xxx, xxx—xxx SJOPT 294 No. of Pages 3, Model NS Please cite this article in press as: Pradeep A.V., et al. Partial HELLP syndrome with unilateral exudative retinal detachment treated conservativelyQ1 . Saudi J Ophthalmol (2014), http://dx.doi.org/10.1016/j.sjopt.2014.03.011
  • 2. 54 (range 0–46), serum alanine aminotransferase (ALT) 93 IU/L 55 (range 0–49), lactate dehydrogenase 1308 IU/L (range 200– 56 400), platelet count of 1.72 lakhs/cu mm (range 1.5–4) and a 57 blood picture of normocytic normochromia with leukocytosis. 58 She was diagnosed with Partial HELLP syndrome was started 59 on calcium blocker, tablet nifedipine 5 mg twice a day along 60 with alfa blocker, tablet prazocin 5 mg twice a day and subse- 61 quently underwent an emergency cesarean section the follow- 62 ing day for non-reactive Non Stress Test. A single live healthy 63 female baby weighing 2.7 kg was extracted. One month prior, 64 her retinal examination was within normal limits. On post 65 operative day one, her BP was 160/100 mm Hg with total 66 bilirubin of 1.99 mg/dl, direct bilirubin 0.83 mg/dl, indirect 67 bilirubin 1.16 mg/dl, AST 22 IU/L, ALT 26 IU/L, blood urea 68 6.22 mg/dl, and serum creatinine 0.8 mg/dl. On the seventh 69 post-operative day, the patient complained of a sudden onset 70 of blurring of vision in the left eye. On examination her visual 71 acuity in the right eye was 6/6 whereas in the left eye it was 72 6/6 parts. Slit lamp examinations of anterior segment of both 73 eyes were unremarkable with normal IOP. Both eyes’ vitreous 74 was clear. Fundoscopy of the left eye showed dumbbell 75 shaped shallow serous retinal detachment in the inferonasal 76 quadrant extending up to the macula as seen in Fig. 1. Fundus 77fluorescein angiogram in the early phase showed an area of 78delayed choroidal filling. In the midphase, the retinal vascula- 79ture was relatively spared without any evident signs of vascular 80occlusion. In the late venous phase, confluent patches were 81seen indicating choroidal hyper permeability and pooling of 82the dye, which was compatible with the diagnosis of exudative 83retinal detachment seen in Fig. 2. The patient was started on 84an antioxidant tablet, once a day and Nepafenac 0.1% eye 85drops four times per day along with bed rest and head end 86elevation. A diagnosis of severe preeclampsia with Partial 87HELLP syndrome complicated with a unilateral serous retinal 88detachment was made. A week later fundoscopy of the left 89eye revealed resolving serous retinal detachment as seen in 90Fig. 3. One Q6month post treatment the patient showed com- 91plete resolution of the detachment of retina with regaining 92of visual acuity. 93Discussion 94Retinal detachment is an unusual but well documented 95phenomenon in hypertensive disorders of pregnancy affect- 96ing 0.9% of patients with HELLP syndrome.12 Retinal detach- 97ment is seven times more common in women with pre- 98eclampsia or eclampsia with HELLP syndrome than those 99without HELLP syndrome.1 Hutchings et al. suggested that 100retinal detachment is a consequence of choroidal vascular 101damage. Choroidal ischemia is secondary to arteriolar vaso- 102spasm which affects the retinal pigment epithelium and 103breaks down the blood retinal barrier. HELLP syndrome 104causes hemolysis of red blood cells leading to focal ischemia 105due to capillary obstruction.13 Retinal detachment in HELLP 106syndrome is commonly seen in the last trimester of preg- 107nancy, but seldom within the first week postpartum. In the 108postpartum period, subretinal fluid is absorbed by retinal 109pigment epithelium and the visual acuity generally improves 110within weeks.6 In our case, the patient with Partial HELLP syn- 111drome had only unilateral serous retinal detachment as com- 112pared to the bilateral detachments reported in the literature. 113Immediate management of HELLP syndrome and delivery of 114the fetus along with timely intervention by the ophthalmolo- 115gist are advisable to reverse any ocular manifestations and 116avoid long term visual sequelae.7 Figure 1. Fundus photo of the left eye. Fundus photo of the left eye showing dumbbell shaped shallow retinal detachment inferior to disk extending up to the macula. Figure 2. Fluorescein angiogram of the left eye. Left eye fluorescein angiogram in the late venous phase showing confluent patches indicating choroidal vasculature hyper permeability and pooling of dye, compatible with the diagnosis of exudative retinal detachment. Figure 3. Fundus photo of the same eye one week later. Fundus photo of the left eye one week later revealed resolving retinal detachment. 2 A.V. Pradeep et al. SJOPT 294 No. of Pages 3, Model NS Please cite this article in press as: Pradeep A.V., et al. Partial HELLP syndrome with unilateral exudative retinal detachment treated conservativelyQ1 . Saudi J Ophthalmol (2014), http://dx.doi.org/10.1016/j.sjopt.2014.03.011
  • 3. 117 Conclusion 118 The case demonstrates that timely intervention and regu- 119 lar follow up visits are essential in pregnant women with pre- 120 eclampsia or eclampsia with HELLP syndrome to avoid visual 121 problems. Hence, all patients with gestational hypertension 122 should undergo a thorough retinal examination. 123 Conflict of interest 124 The authors declared that there is no conflict of interest. 125 References 126 1. Vigil-De Gracia P, Ortega-Paz L. Retinal detachment in association 127 with pre-eclampsia, eclampsia and HELLP syndrome. Int J Gynecol 128 Obstet 2011;114:223–5. 129 2. Burke JP, Whyte I, MacEwen CJ. Bilateral serous retinal detachment 130 in HELLP syndrome. Acta Ophthalmol 1989;67(3):322–4. 131 3. Ian Donald, Hypertensive disorders in pregnancy. In: Renu Misra, 132 editors. Ian Donald’s Practical Obstetric Problems, New Delhi: BI 133 publications pvt ltd; 2008, p. 294. 1344. Levavi H, Neri A, Zoldan J, Segal J, Ovadia J. Pre-eclampsia, ‘‘HELLP’’ 135syndrome and postictal cortical blindness. Acta Obstet Gynecol 136Scand 1987;66:91–2. 1375. Jaffe G, Schatz H. Ocular manifestations of preeclampsia. Am J 138Ophthalmol 1987;103:309–15. 1396. Gundlach E, Junker B, Gross N, Hansen LL, Pielen A. Bilateral serous 140retinal detachment. Br J Ophthalmol 2013;97(7):939–40. 1417. Schönfeld C-L. Bilateral Exudative Retinal Detachment in HELLP 142Syndrome. Case Rep Ophthalmol 2012;3(1):35–7. 1438. Lin P, Hahn P, Fekrat S. Peripheral retinal vascular leakage 144demonstrated by ultra-widefield fluorescein angiography in 145preeclampsia with HELLP syndrome. Retina 2012;32(8):1689–90. 1469. Mayer WJ, Hakim I, Ulbig MW, Kernt M, Haritoglou C. Non-mydriatic 147wide field fundus photography in bilateral serous retinal detachment 148due to HELLP syndrome. Arch Gynecol Obstet 2012;286(3):819–20. 14910. Ramaesh K, Nagendran S, Saunders DC. Choroidal ischaemia and 150serous retinal detachment in toxemia of pregnancy. Eye 1511999;13:795–6. 15211. Sathish S, Arnold JJ. Bilateral choroidal ischaemia and serous retinal 153detachment in pre-eclampsia. Clin Exp Ophthalmol 2000;28:387–90. 15412. Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA. 155Maternal morbidity and mortality in 442 pregnancies with hemolysis, 156elevated liver enzymes, and low platelets (HELLP syndrome). Am J 157Obstet Gynecol 1993;169:1000–6. 15813. Hutchings K, Sangalli M, Halliwell T, Tuohy J. Bilateral retinal 159detachment in pregnancy. Aust NZ J Obstet Gynaecol 1602002;42:409–11. 161 Partial HELLP syndrome with unilateral exudative retinal detachmentQ1 3 SJOPT 294 No. of Pages 3, Model NS Please cite this article in press as: Pradeep A.V., et al. Partial HELLP syndrome with unilateral exudative retinal detachment treated conservativelyQ1 . Saudi J Ophthalmol (2014), http://dx.doi.org/10.1016/j.sjopt.2014.03.011