The optic fundus of secondary polycythaemia

A 32-year-old male presented with a throbbing holocranial headache of 3 months’ duration. The headache was worse on lying down, disturbed his sleep and was associated with blurred vision. He was treated for sinusitis and migraine by primary care physicians during this period. Although plethoric and cyanosed, he was haemodynamically stable with an oxygen saturation of 85% on ambient air. Review of his medical records confirmed that he had a perimembranous ventricular septal defect of 26mm with pulmonary hypertension (pressure gradient of 60mm Hg) with reversal of cardiac shunt. His haemoglobin was 24.1g/dl with a packed cell volume (PCV) of 70%. The best corrected vision of both eyes was 6/24 with bilateral papilloedema, dilated retinal veins and scattered retinal haemorrhages (Figure 1). Phlebotomy at regular intervals resulted in resolution of the headache and the distinct changes in the optic fundus (Figure 2). Corrected vision of both eyes improved to 6/9.

Figure 1 Optic fundus – before treatment