Anaemic Retinopathy with Roth Spots and Subhyaloid Haemorrhage in Severe Megaloblastic Anaemia with Haemolysis: A Case Report

Anaemic retinopathy comprises retinal changes, including flame-shaped and dot-blot haemorrhages, white- centred Roth spots, cotton-wool spots and, rarely, preretinal (subhyaloid) haemorrhage, that occur in severe anaemia, particularly when haemoglobin falls below 5 - 8 g/dL or is accompanied by thrombocytopenia. Vitamin B12 deficiency is a recognised cause of profound megaloblastic anaemia with haemolysis resulting from ineffective erythropoiesis. We report a 19-year-old female with no history of diabetes mellitus or hypertension who presented with fever, abdominal pain, vomiting, loose stools, and palpitations, and was found to have sepsis with shock and profound anaemia (haemoglobin 3.4 g/dL) with thrombocytopenia (platelet count 93 × 10³/µL). Investigations revealed a markedly low vitamin B12 level (< 50 pg/mL), elevated lactate dehydrogenase (3017 U/L), and raised indirect bilirubin with a negative direct Coombs test, consistent with severe megaloblastic anaemia with ineffective erythropoiesis and haemolysis. During hospitalisation, she developed blurred vision with loss of colour vision. Dilated fundus examination demonstrated multiple bilateral retinal haemorrhages, subhyaloid haemorrhage, and Roth spots, consistent with anaemic retinopathy. Magnetic resonance imaging of the brain was normal, and neurology evaluation revealed no alternative central cause. She was managed with blood transfusion and inotropic support in the Intensive Care Unit (ICU), but her family opted for discharge against medical advice before bone marrow aspiration could be performed. This case underscores the importance of prompt dilated fundus examination in patients with severe anaemia and visual symptoms, and highlights anaemic retinopathy as a distinctive but underrecognised ocular manifestation of severe haematological disease, including vitamin B12 deficiency.