Case No. On follow-up, the macular edema resolved in the right eye C. The clinical picture in D is the left eye. Along with systemic features of anemia per se, and in relation to the primary etiology leading to the anemia, ocular findings can be classified as features common to all anemias or specific features due to specific etiologies.
Rarely, loss of vision can be a presenting complaint, because most cases are asymptomatic. At the macula, hemorrhages, edema, or hard exudates can cause impairment of vision. Alternatively, vision loss may occur due to disc edema or optic neuropathy. Hemorrhages: Superficial, flame-shaped hemorrhages located in the nerve fiber layer are the most common finding in anemic retinopathy. In a few cases, dot and blot hemorrhages in deeper retinal layers may be noted.
Rarely, blood may be present in the subhyaloid plane or in the vitreous. Roth spots may be seen. The white centers in Roth spots can be due to inflammatory infiltrates, fibrin and platelets, neoplastic cells, or focal areas of ischemia. Cotton wool spots: Retinal nerve fiber layer infarction due to retinal hypoxia in anemia causes these superficial fluffy white lesions. Retinal edema: The microtrauma of the vessel wall secondary to raised transmural pressure leads to leakage. This in turn leads to retinal edema.
Hard exudates: These may be seen due to resolved retinal edema. When these are severe and located at the macula, macular star is seen.
Vessel changes: Arteries are attenuated and pale, and veins are dilated and tortuous. These findings are seen more as the severity of anemia increases. Figure 2. Follow-up scans show a resolution in increased central foveal thickness in the right eye C and symmetry of architecture with that of the left eye D. Optic nerve changes: Edema or, in later stages of optic neuropathy, optic disc pallor is seen. Iron deficiency anemia: Besides the routine changes, other described findings include central retinal vein occlusion, retinal artery occlusion, disc edema, and anterior ischemic optic neuropathy.
Vitamin B12 deficiency anemia: This condition causes optic neuropathy, which is evident as disc pallor. Sickle cell anemia: Proliferative changes are seen in the retina secondary to vaso-occlusion, which can lead to vitreous hemorrhage and retinal detachment. Choroidal infarcts can occur due to the sickling of red blood cells.
It is interesting to note that conjunctival sickling sign and areas of iris atrophy and neovascularization occur in this disease. Myeloproliferative disorders: Roth spots, leukemic infiltrates in the retina, choroidal infiltration with secondary serous retinal detachment, microaneurysms, and vascular sheathing may be seen.
Thalassemia: Retinal pigment epithelial changes are seen. Malaria: Anemia and raised intracranial pressure due to cerebral malaria can cause retinal changes and disc edema. Ocular investigations are indicated only if treatment is being planned. Fluorescein angiography may demonstrate a delay in the arteriovenous transit time in cases of venous occlusion.
Retinopathy in anemia can also be seen in oncology patients and in those with infectious endocarditis or autoimmune diseases. Second, anemia can be caused by the destruction of red blood cells and, finally, anemia can be the result of blood loss.
Hematologists and oncologists are exposed to patients with anemia from all of these pathophysiologic origins. Therefore, the ability to recognize the signs and symptoms of the condition and understand the etiology and pathophysiology behind it are important for the recommendation of appropriate management. Recognizing and treating anemia in cancer patients can be challenging because the origin of the condition may be multifactorial.
Anemia in a patient with cancer may be the result of the malignancy itself, the treatment prescribed for the malignancy, or an unassociated underlying condition. Suppression of the production of red blood cells can be caused by cancer cells infiltrating bone marrow or by myelotoxic chemotherapeutic agents. Anemia due to the destruction of red blood cells can occur due to inflammatory cytokines produced by the tumor, or hemolysis 2 from chemotherapeutic agents such as oxaliplatin, fludarabine and interferon.
Finally, anemia can also be related to patient characteristics that are not necessarily connected to the cancer or cancer treatment at all. In some cases where an individual already has anemia, a cancer diagnosis can compound the severity of the anemia. Although a low Hb level may be the first indication of anemia, it should prompt physicians to conduct a thorough patient history and physical examination.
On a broader level, the health care provider should ask the patient about the onset and duration of symptoms, family medical history, comorbidities and any medications he or she is currently taking. An examination for more specific symptoms is also necessary as a decrease in red blood cell levels, which diminishes the oxygen-carrying capacity of the blood, can ultimately lead to hypoxia and hypoxemia, eventually having an effect on multiple biological and organ systems.
However, symptoms can vary greatly because anemia can affect so many different organ systems, including the neurological system eg, fatigue, sleep disorders, impaired cognitive function, depression , immune system eg, impaired T-cell and macrophage function , cardiorespiratory function eg, tachycardia, palpitations, dyspnea and more eg, pallor of the skin, fluid retention.
This helps limiting the causes of anemia of chronic disease. From a pathophysiological point of view, anemia of chronic disease is mediated by inflammatory cytokines This morphological characteristic was the second most frequent form, with This, in turn, may be differential diagnosis of anemia of chronic disease or iron deficiency anemia; in this case, it is essential to determine the serum ferritin.
Note that this protein, responsible for iron reserve, was not determined in any of the hospitalized patients. Rangel et al. The Israeli 19 study showed It is noticed that this upward distribution according to functional class would be expected and found in other studies 11,19 , which was not found in this study, where This may be due, among other causes, to a different population profile in the service concerned or to the subjectivity of the NYHA classification, which depends on the views and interpretation of the physician to determine it.
Thinking of a public health system, this implies expenses with hospitalizations in patients that could be managed on an outpatient basis or patients seeking tertiary care as a gateway. A second reasonable question would be the existence of a parallel between FC and severity of the disease. Most cases of anemia Though these patients are classified as mild or moderate degree, the possibility of treatment should always be a clinical issue.
Treatment of anemia is related to improvement in the patient's hemodynamic status. Besides this, patients present improvement in NYHA functional class, drop in the number of hospitalizations, reduced doses of oral and intravenous diuretic furosemide and considerable improvement in the symptoms of fatigue 5. Silverberg et al. This association between renal failure, anemia and HF generates a vicious cycle and self-feedable It is worth noting that there is no consensus in the literature regarding the management of cardiac patients who develop anemia, but major studies point out the relevance of this issue The importance of treatment of anemia is related to the mortality of patients.
Larger studies consider the higher mortality rate for patients developing anemia to be significant. Ezekowitz et al. Horwich et al. Similar results can be seen in the systematic review by Groenveld et al.
Mortality parameters are also associated with sex, with a predominance of the male sex 10, The study limitations are due mainly to the fact that the data collection was retrospective, which only allowed the analysis of information from medical records.
Besides, using data from a single service may not have represented the sample population in the region. Larger multicenter studies are of great importance to define more accurately the prevalence of anemia found in patients hospitalized with HF. Furthermore, randomized clinical trials defining the actual validity of pharmacological intervention in this group turns out to be a focal point for new therapies to prevent the progression of the condition and negative outcome for the patient.
The prevalence of anemia in patients with HF was higher in older age groups, in FC III and IV, and the main morphological characteristic was normocytic and hypochromic. I Latin American Guidelines for the assessment and management of decompensated heart failure. Arq Bras Cardiol. Eur Heart J. Bone marrow dysfunction in chronic heart failure patients. Eur J Heart Fail. The importance of anemia and its correction in the management of severe congestive heart failure.
Sica DS. Pharmacotherapy in congestive heart failure: ACE inhibitors and anemia in congestive heart failure. Congest Heart Fail. Anand IS.
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