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
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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
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Please cite this article in press as: Pradeep A.V., et al. Partial HELLP syndrome with unilateral exudative retinal detachment treated conservativelyQ1 . Saudi J
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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.
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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.
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Partial HELLP syndrome with unilateral exudative retinal detachmentQ1 3
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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