Delhi Journal of Ophthalmology

Lipemia Retinalis in a 25-day Old Neonate: A case report

Santosh Kumar Mahapatra, Anuja Mohanty
J.P.M. Rotary Eye Hospital and Research Institute, Cuttack, Odisha, India

Corresponding Author:

Anuja Mohanty (DNB)
Department of Vitreo-Retina,
JPM Rotary Eye Hospital & Research Institute,Sector-6, CDA, Cuttack, Odisha, India 
E-mail: anujamhnt@gmail.com

Received: 21-MAR-2020

Accepted: 31-MAR-2020

Published Online: 09-OCT-2020

DOI:http://dx.doi.org/10.7869/djo.575

Abstract
A 25-day old neonate  presented with complaints of greenish black stools. It was a full term LSCS delivery born of a non-consanguineous marriage. There was no history of any oxygenation/phototherapy. Birth weight was 3.5  kg and the baby had cried after birth. She was exclusively breastfed. On evaluation she had high blood levels of cholesterol and triglycerides suggesting a diagnosis of type IIb hyperlipidemia (familial combined hyperlipidemia). She was referred by paediatrician for ophthalmic examination. Funduscopy showed a manifestation of grade III lipemia retinalis. Physical examination revealed hepatosplenomegaly on per abdomen. She was treated with antibiotics, i.v fluids and dietary modifications. The blood reports of both parents showed lipoproteinemia and hypercholesterolemia.

Keywords :Lipemia retinalis, hypertriglyceridemia, creamy white serum, neonate, funduscopy

Introduction
Lipemia retinalis was first described by Heyl in 18801 and is caused by hypertriglyceridemia (serum triglycerides(TG)> 2500mg/dl). The fundus findings result from light scatter induced by the triglyceride-laden chylomicrons in the plasma.2 It serves as a vital clinical sign of hypertriglyceridemia because asymptomatic triglycerides elevation may delay treatment of a potentially lethal metabolic disorder.3

Case Report
A 25-day old neonate with complaints of greenish black stools was referred to us by paediatrician for funduscopy. She was a full term baby born by LSCS and product of non-consanguineous marriage; with birth weight of 3.5 kg. The baby had cried after birth and there was no history of oxygen supplementation/phototherapy. She was exclusively breastfed. Her blood sample was creamy white in colour (Figure 1). The blood investigations showed a very high apolipoprotein (26.67g/L), cholesterol (1912mg/dl), triglycerides (44000mg/dl), LDL (631mg/dl) along with raised serum lipase (1791U/l), CRP (40.09 mg/l) and stool RBCs (20-30/hpf). Systemic examination revealed hepatosplenomegaly. Ophthalmic examination showed a normal anterior segment with creamy white vessels all over the fundus suggestive of grade III lipemia retinalis (Figure 2). The baby was treated with antibiotics, i.v. fluids, dietary modifications and restriction of breast feeding. She was lost to follow up. The blood reports of both parents showed lipoproteinemia and hypercholesterolemia which prompts the likely diagnosis of type IIb hyperlipidemia (familial combined hyperlipidemia).The constellation of findings prompted us to report this rare case as very few similar case scenarios have been reported in literature.


Figures 1: Creamy white blood sample of the baby


Figure 2: Fundii of both eyes showing grade III lipemia retinalis



Discussion 
Lipemia retinalis is an asymptomatic condition that can appear when high levels of triglycerides are present in the circulatory system. The retina’s white milky aspect occurs when the plasma levels are near to 2000 to 2500 mg/dL or more.The fundus changes have been graded: grade I (early) - white and creamy aspect of the peripheral retina vessels (TG 2500-3499mg/dl); grade II (moderate) - the creamy color of the vessels extends towards the optic disc (TG 3500-5000mg/dl);grade III (marked) - the retina appears salmon pink and all vessels - arteries and veins present a milky aspect (TG > 5000mg/dl).3,4 The treatment  for these cases are restriction of fat in the diet (less than 10 g/day) and elevated intake of protein and carbohydrate. The ingestion of fat soluble vitamin supplements is also necessary. Exchange transfusion may be needed in severe cases.No more than 20 cases of lipemia retinalis have been reported till 2018 in infants less than 16weeks.5 Funduscopy is of paramount importance in all cases of  hyperlipidemia with creamy white serum in newborns to rule out lipemia retinalis and establish the diagnosis of specific dyslipidemias and plan for early management. 

References
  1. Heyl A. Intra-ocular lipæmia. Trans Am OphthalmolSoc 1880;3:54-66.
  2. Nagra PK, Ho AC, Dugan JD Jr. Lipemia retinalis associated with branch retinal vein occlusion. Am J Ophthalmol 2003;135:539-42.
  3. Horton M, Thompson K. Lipemia retinalis preceding acute pancreatitis. Optometry 2011;82:475-80.
  4. Cypel M, Manzano R, Dos Reis FA, et al. Lipemia retinalis in a 35-day old infant with hyperlipoproteinemia: case report. Arq Bras Oftalmol 2008;71:254-6.
  5. Shinkre ND, Usgaonkar UP. Lipemia retinalis in a 27 day old neonate: A case report. Indian J Ophthalmol 2019;67:954-7.

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Mahapatra SK, Mohanty ALipemia Retinalis in a 25-day Old Neonate: A case report.DJO 2020;31:76-77

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Mahapatra SK, Mohanty ALipemia Retinalis in a 25-day Old Neonate: A case report.DJO [serial online] 2020[cited 2020 Dec 5];31:76-77. Available from: http://www.djo.org.in/articles/31/1/lipemia-retinalis-in-a-25-day-old-neonate-a-case-report.html