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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 3  |  Issue : 3  |  Page : 194-196

Unusual presentation of lipemia retinalis in pregnancy


Department of Ophthalmology, Chettinad Hospital and Research Institute, Kelambakkam, Tamil Nadu, India

Date of Web Publication13-Aug-2014

Correspondence Address:
A M Raja
19, Lake View Road, Brindhavan Apartments, Flat No 5, Brindhavan Nagar, Adambakkam, Chennai - 600 088, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.138606

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  Abstract 

A 27-year-old female with 6 months amenorrhea and pregnancy induced hypertension was referred from Obstetrics Department for routine fundus examination. Vision and anterior segment were normal. Fundus examination showed media clear and disc normal. Vessels showed yellowish orange in color, becoming more paler toward periphery and no distinction between arteries and veins. On suspecting lipemia retinalis, we advised lipid profile, which showed very high triglyceride levels. The patient was referred to endocrinologist for opinion. Even if it is asymptomatic condition, it should not be ignored and we should advise immediate treatment to prevent cardiovascular complications and fetal anomalies.

Keywords: Lipemia retinalis, pregnancy, triglycerides


How to cite this article:
Raja A M, Janti S, Charanya C, Matheen A. Unusual presentation of lipemia retinalis in pregnancy. Int J Health Allied Sci 2014;3:194-6

How to cite this URL:
Raja A M, Janti S, Charanya C, Matheen A. Unusual presentation of lipemia retinalis in pregnancy. Int J Health Allied Sci [serial online] 2014 [cited 2019 Sep 16];3:194-6. Available from: http://www.ijhas.in/text.asp?2014/3/3/194/138606


  Introduction Top


Heyl first described lipemia retinalis as retinal alterations due to hyperlipidemia in which creamy white appearance in retinal blood vessels due to light dispersions by triglycerides (TGL) laden chylomicrons in the plasma. [1],[2] According to Nagra et al. lipemia retinalis is thought to be directly correlated with the serum triglyceride level and typically the retinal findings do not occur until the triglyceride level reaches 2500 mg/dl. [3] Even if it is asymptomatic, it should not be ignored and we should advise immediate treatment to prevent cardiovascular complications and fetal anomalies when this condition is seen in pregnant women. This case is presented as lipema retinalis is rare in pregnancy and cholesterol levels should be monitored and lipid lowering measures should be taken to prevent fetal abnormalities.


  Case report Top


A 27-year-old female was referred from Obstetrics Department to Ophthalmology outpatient department for routine fundus examination. She had 6 months of amenorrhea with pregnancy induced hypertension. On examination, visual acuity in both eyes was 6/6 and color vision and intra ocular pressure were normal. Anterior segment examination was normal. Both eyes fundus examination showed media clear and disc normal. Vessels were yellowish orange in color [Figure 1] and [Figure 2]. The peripheral retinal vessels were pale and there was no distinction between arteries and veins [Figure 3]. Foveal reflex was seen in macula.
Figure 1: Right eye shows yellowish orange coloured retinal vessels and no distinction between arteries and veins

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Figure 2: Left eye shows yellowish orange coloured retinal vessels and no distinction between the arteries and veins

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Figure 3: Peripheral pale retinal vessels

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She did not have xanthoma or xanthelasma. We suspected lipema retinalis from the above findings and immediately referred the patient to endocrinologist. We advised routine blood investigations and lipid profile for the patient. Total cholesterol >800 mg/dl, high density lipoprotein (HDL) 21 mg/dl, TGL 3564 mg/dl, low density lipoprotein (LDL) 284 mg/dl, very LDL (VLDL) 194 mg/dl, total cholesterol/HDL 23, LDL/HDL was 13. Blood sugar, serum urea, and creatinine were normal. Thyroid profile, liver function test were normal. Electrocardiography and echocardiogram were within normal limits. In her family, her twin sister also has increased values of total cholesterol and TGL (cholesterol - 134 mg/dl and TGL - 1320 mg/dl). No history of hypertension, diabetes, cardiac disease in the family. Endocrinologist suspected familial hyper lipoproteinemia and statins are contraindicated in pregnancy so started on bile acid sequestrants. The patient came for follow-up after 12 weeks and fundus showed normal appearance [Figure 4] and [Figure 5]. The lipid levels after treatment were total cholesterol 268 mg/dl, LDL 128 mg/dl, HDL 48 mg/dl, TGL 262 mg/dl, and VLDL was 62 mg/dl.
Figure 4: Normal fundus after 12 weeks of treatment

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Figure 5: Left eye normal fundus following 12 weeks of treatment

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  Discussion Top


Heyl first described the term lipemia retinalis on 1980. [1] Hyperlipidemia can cause retinal alterations called "lipemia retinalis". It is a rare asymptomatic condition associated with hyper lipoprotienemias. It causes creamy white appearance in retinal blood vessels due to light dispersions by TGL laden chylomicrons in the plasma. [2] The pathological appearance of lipemia retinalis believed to be due to visualization of lactescent of a hyperlipidemic patient. The cause of lactescent serum was discussed in 1949 by Ahrens and Kunkel. [2] They postulated that since particles in suspension need to be a certain size in order to scatter light and produce a turbid appearance, lipemic sera must contain particles of at least 0.25 wavelength of visible light that is, about 100 nm. If a sample of hyper lipidemic serum is allowed to stand at 4°C, chylomicrons form a hazy surface layer [Figure 6]. Lactescent/lipemic serum or plasma is caused by increased concentrations of triglyceride-rich lipoproteins (chylomicrons or VLDL. Hypercholesterolemia alone is not associated with lipemia. Triglyceride content can be estimated by assessing serum lactescence. Clear serum usually has a triglyceride content <200 mg/dl. Serum is hazy with a triglyceride concentration of 300 mg/dl and serum has a skim milk appearance with a triglyceride concentration around 1000 mg/dl. Chylomicrons have low density and therefore will float to the surface of a serum/plasma sample with time. Refrigeration of the serum sample for about 12-16 h may be a helpful tool to determine if the lipemia is due to the presence of chylomicrons or VLDL. Chylomicrons will float to the top and form a cream layer. Turbidity below or without a cream layer suggests the presence of excess VLDL.
Figure 6: Lactescence of serum in hyperlipidemic patients at 4° C

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According to Nagra et al. lipemia retinalis is thought to be directly correlated with the serum triglyceride level. [3] In general, the retinal findings do not occur until the triglyceride level reaches 2500 mg/dl. Based upon the fundus findings and TGL levels it can be graded in to three groups [Table 1]. [4],[5],[6]
Table 1: WHO classification for hyperlipidemia associated ocular manifestations

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The Third Report of the National Cholesterol Education Program (NCEP) Expert Panelon the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) defines lipemia retinalis as one of the outcomes of hyper triglyceridemia [Table 2]. [7] According the NCEP, optimal serum LDL cholesterol level should be below 100 mg/dl (LDL above 190 mg/dl is classified as very high). Hyper lipoproteinemia may be primary or secondary.
Table 2: Lipoprotein pattern with corresponding ocular features

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In electroretinography, reduced a- and b-waves in both cone and rod responses were described by Lu et al. [7] Lipemia retinalis is a asymptomatic condition, which does not require any specific treatment. [8],[9] Once triglyceride levels return to normal, the retinal findings of lipemia retinalis resolve immediately.

 
  References Top

1.Martinez KR, Cibis GW, Tauber JT. Lipemia retinalis. Arch Ophthalmol 1992;110:1171.  Back to cited text no. 1
    
2.Ahrens EH Jr, Kunkel HG. The stabilization of serum lipid emulsions by serum phospholipids. J Exp Med 1949;90:409-24.  Back to cited text no. 2
[PUBMED]    
3.Nagra PK, Ho AC, Dugan JD Jr. Lipemia retinalis associated with branch retinal vein occlusion. Am J Ophthalmol 2003;135:539-42.  Back to cited text no. 3
    
4.Cypel M, Manzano R, Dos Reis FA, Ishida N, Ayhara T. Lipemia retinalis in a 35-day-old infant with hyperlipoproteinemia: Case report. Arq Bras Oftalmol 2008;71:254-6.  Back to cited text no. 4
    
5.Horton M, Thompson K. Lipemia retinalis preceding acute pancreatitis. Optometry 2011;82:475-80.  Back to cited text no. 5
    
6.Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-97.  Back to cited text no. 6
[PUBMED]    
7.Lu CK, Chen SJ, Niu DM, Tsai CC, Lee FL, Hsu WM. Electrophysiological changes in lipaemia retinalis. Am J Ophthalmol 2005;139:1142-5.  Back to cited text no. 7
    
8.Kurz GH, Shakib M, Sohmer KK, Friedman AH. The retina in type 5 hyperlipoproteinemia. Am J Ophthalmol 1976;82:32-43.  Back to cited text no. 8
[PUBMED]    
9.Vinger PF, Sachs BA. Ocular manifestations of hyperlipoproteinemia. Am J Ophthalmol 1970;70:563-73.  Back to cited text no. 9
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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