title: White centered retinal hemorrhages in vitamin b(12) deficiency anemia.
abstract: BACKGROUND
  To report a case of severe vitamin B(12) deficiency anemia presenting with white centered retinal hemorrhages.
  
  
  METHODS
  Interventional case report.
  
  
  RESULTS
  A 40-year-old man, general practitioner himself, presented with a 1-day history of diminished left visual acuity and a drop-shaped central scotoma. The corrected visual acuities were 20/20, OD and 20/100, OS. Ophthalmic examination revealed bilaterally pale tarsal conjunctiva, discretely icteric bulbar conjunctiva and disseminated white centered intraretinal hemorrhages with foveal involvement. OCT imaging through these lesions revealed a retinal thickening caused by a sub-ILM accumulation of hyperreflective and inhomogeneous deposits within the nerve fiber layer. Immediate laboratory work-up showed severe megaloblastic anemia caused by vitamin B(12) deficiency requiring erythrocyte transfusions.
  
  
  CONCLUSIONS
  Most reports of white centered retinal hemorrhages have been described in patients with leukemic retinopathy and bacterial endocarditis. It is interesting that this case of vitamin B(12) deficiency anemia retinopathy has a clinically indistinguishable fundus appearance. This is probably due to the common pathology of capillary disruption and subsequent hemostatic fibrin plug formation. In megaloblastic anemia, direct anoxia results in endothelial dysfunction. The loss of impermeability allows extrusion of whole blood and subsequent diffusion from the disrupted site throughout and above the nerve fiber layer. Therefore the biomicroscopic pattern of white centered hemorrhages observed in anemic retinopathy is most likely due to the clot formation as the reparative sequence after capillary rupture.
authors.affiliation: Department of Ophthalmology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Claus
authors.initials: C
authors.lastname: Zehetner
authors.forename: Nikolaos E
authors.initials: NE
authors.lastname: Bechrakis
references.citation: Arch Ophthalmol. 1961 Oct;66:490-508
references.pmid: 13860566
references.citation: Br J Ophthalmol. 1969 Mar;53(3):145-60
references.pmid: 5252200
references.citation: Am J Ophthalmol. 1968 Mar;65(3):435-9
references.pmid: 5640547
references.citation: Ophthalmology. 1980 Jan;87(1):66-9
references.pmid: 7375087