Rare Case of Idiopathic Thrombocytopenia Causing Retrobulbar Hemorrhage

Immune thrombocytopenia purpura (ITP) is defined as a platelet count lower than 100 × 10ˆ9/L, in the absence of known abnormalities in white blood cells, normal hemoglobin with generalized purpuric rash: making it a diagnosis of exclusion.1-2 ITP is due to destruction of platelets in the spleen via autoantibodies, resulting in reduced platelet counts.3 Though rare, ITP is linked with spontaneous retrobulbar hemorrhage (SRH). If ITP is identified, prompt treatment is needed to prevent loss of vision. An 80-year-old non-smoking woman with a history of diabetes, hypertension, and alpha thalassemia minor presented with a one-day history of a right occipital lobe headache and right sided ocular dysfunction. Workup showed a very low platelet count of 35,000/mm³, and elevated D-Dimer at 12,485 ng/mL. MRI revealed a new hemorrhage in the retrobulbar area causing right-sided proptosis. MRA showed no arteriovenous shunting, and the right ophthalmic artery was patent. Therapy for seven days with cryoprecipitate, IVIG, and steroids was started, symptoms resolved, and patient was discharged. The relationship between ITP and non-traumatic sub-periosteal orbital hemorrhage (NTSOH) is unclear, but its occurrence in the setting of anemia is often seen. To best of our knowledge this is a rare case of NTSOH in a patient with mild anemia and acute ITP in the absence of other risk factors such as trauma or excessive Valsalva events.