CASE REPORT

A 40‐year‐old male with no known co‐morbidities presented to our emergency out‐patient department with diminution of vision in both eyes of 05 days duration. He also gave a history of fever, dry cough, and myalgia 20 days back and the nasopharyngeal swab of the patient tested positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). He was admitted as a mildly symptomatic Coronavirus disease 2019 (COVID‐19) positive case and was managed conservatively as per COVID‐19 treatment guidelines for 14 days and discharged. During his hospital stay, his routine haematological parameters were within normal range.

On ocular evaluation, his best‐corrected visual acuity was 20/200 in the right eye and 20/400 in the left eye. The anterior segment examination of both eyes was normal with brisk pupillary reflexes. Dilated fundus examination revealed bilateral large premacular “boat‐shaped” haemorrhages (blue arrows) of 4‐disc diameter size in the left eye and 3‐disc diameter size in the right eye with few superficial retinal nerve fibre layer haemorrhages in the posterior pole of the retina (Figure 1A,B). There was no evidence of cotton wool spots, vasculitis, retinal neovascularisation or vitreous haemorrhage suggestive of any ischaemic condition. The patient gave no history suggestive of a bleeding tendency or any concurrent viral infection.

A complete haematological evaluation was done to determine the cause of spontaneous sub‐hyaloid haemorrhage. His blood investigations revealed a white blood cell count (WBC) of 1500/L, haemoglobin of 4g/L, and platelet of 31,000/μl which were suggestive of pancytopenia. Serum bilirubin, uric acid, liver function tests, renal parameters, folate, and vitamin B₁₂ were within the normal range. The patient was referred to a haematologist for evaluation of pancytopenia and bone marrow biopsy showed normal trilineage haematopoiesis with no sign of lymphoma, fibrosis, or myelodysplasia. In view of preceding COVID‐19 infection and absence of a secondary obvious cause of pancytopenia, he was diagnosed as a case of COVID‐19 induced pancytopenia.

He was immediately treated with double frequency Nd‐YAG laser hyaloidotomy in both eyes for premacular sub‐hyaloid haemorrhage with a 532 nm green laser (Suprascan, Quantel medicals) with power 150 mW, duration 0.02ms, 6 spots using a macular area centralis lens. Both eyes showed progressive resolution of pre‐macular haemorrhages and improvement in visual acuity to 20/30 in the right eye and 20/40 in the left eye at four weeks. He was also concurrently treated with packed cells and platelets transfusion with subsequent improvement of haemoglobin levels to 9 g/dl and platelet count to 80,000/μl at last follow‐up with no recurrence of retinal haemorrhages or other signs of bleeding manifestations.

中文翻译：

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双侧黄斑前玻璃体下出血-揭露COVID-19引起的全血细胞减少

案例报告

一名不明并发疾病的40岁男性在我们的急诊科就诊，病程为05天，双眼均视力减退。他还给出了20天前的发烧，干咳和肌痛的病史，患者的鼻咽拭子检测出严重的急性呼吸综合征冠状病毒2（SARS-CoV-2）阳性。他被接纳为2019年轻度症状性冠状病毒病（COVID-19）阳性病例，并按照COVID-19治疗指南进行了14天的保守治疗并已出院。在他住院期间，他的常规血液学参数在正常范围内。

通过眼部评估，他的最佳矫正视力在右眼为20/200，在左眼为20/400。双眼前段检查正常，瞳孔反射活跃。眼底扩大检查发现双侧大黄斑前“舟状”出血（蓝色箭头）在左眼为4盘直径大小，在右眼为3盘直径大小，而在后极的极少的视网膜神经纤维层浅层出血视网膜（图1A，B）。没有证据表明存在任何缺血性疾病的棉毛斑，血管炎，视网膜新血管形成或玻璃体出血。该患者无病史，无出血倾向或并发病毒感染。

进行了完整的血液学评估，以确定自发性透明下环出血的原因。他的血液检查显示白细胞计数（WBC）为1500 / L，血红蛋白为4g / L，血小板为31,000 /μl，提示全血细胞减少。血清胆红素，尿酸，肝功能检查，肾参数，叶酸和维生素B ₁₂均在正常范围内。该患者被转诊至血液学家以评估全血细胞减少症，骨髓活检显示正常的三系造血功能，无淋巴瘤，纤维化或骨髓增生异常的迹象。鉴于先前发生过COVID-19感染，并且没有继发性明显的全血细胞减少症的原因，他被诊断为COVID-19诱导的全血细胞减少症。

立即用532 nm绿色激光（功率150 mW，持续时间0.02ms，使用黄斑中央区镜片治疗532 nm的532 nm绿色激光，双眼Nd-YAG激光玻璃体切开术治疗双眼黄斑前透明膜下出血）。 。双眼在四周时显示出黄斑前出血的逐步消退，右眼视力提高到20/30，左眼视力提高到20/40。在最后一次随访中，他还同时接受了细胞充填和血小板输注治疗，随后血红蛋白水平提高至9 g / dl，血小板计数提高至80,000 /μl，无视网膜出血复发或其他出血表现。