European Journal of Pediatrics

, Volume 178, Issue 6, pp 957–960 | Cite as

Routine funduscopy in immune thrombocytopenic purpura—is it really necessary?

  • Tali Capua
  • Neta CohenEmail author
  • Adi Anafy
  • Dana Greisman
  • Dror Levin
  • Ayelet Rimon
Short Communication


Immune thrombocytopenic purpura (ITP) is a common cause of symptomatic thrombocytopenia in children, most of whom present with cutaneous and mucosal bleeding. Complications, such as intracranial hemorrhage and occult hemorrhage from various sites, are rare, and retinal hemorrhage is exceptionally rare. Our institutional clinical practice guidelines for managing ITP in the pediatric emergency department (PED) include routine funduscopy. The aim of this retrospective case series is to provide evidence-based recommendations for a tertiary care PED work-up of ITP, with special emphasis on the guidelines for funduscopy. The medical records of all pediatric patients diagnosed with ITP over a 4-year period (2013–2016) who had a platelet count < 50,000/mm3 were retrieved and reviewed. Seventy-five patients with thrombocytopenia (platelet count < 50,000/mm3) were diagnosed as having ITP in the PED. Sixty-one (79%) of these patients underwent funduscopy and retinal hemorrhage was ruled out in all of them, indicating that retinal hemorrhage as a complication of ITP is very rare.

Conclusion: Our data suggest that funduscopy should not be performed routinely on pediatric ITP patients, but rather be reserved for those who present with concurrent anemia or visual complaints.

What is Known:

Many internal institutional protocols in Israel call for retinal hemorrhage bleeding surveillance in work up of ITP. Our study found no case of ITP with retinal bleeding.

What is New:

Many internal institutional protocols in Israel call for retinal hemorrhage bleeding surveillance in work up of ITP. Our study found no case of ITP with retinal bleeding.


Funduscopy Immune thrombocytopenic purpura Occult bleeding Retinal hemorrhage 



Complete blood count


Intracranial hemorrhage


Immune thrombocytopenic purpura


Pediatric emergency department


Pediatric intensive care unit


Standard deviation


Authors’ contributions

Tali Capua and Neta cohen contributed significantly and equally to the planning of the study and the study desing, performed statsitical analysis and did major manuscript preparation. Adi Anafy and Dana Greisman collected data. Dror Levin contributed for manuscript expertise. Ayelet Rimon contributed significantly for manuscript editing and expertise.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Carraro MC, Rossetti L, Gerli GC (2001) Prevalence of retinopathy in patients with anemia or thrombocytopenia. Eur J Haematol 67(4):238–244CrossRefGoogle Scholar
  2. 2.
    Flores A, Buchanan GR (2016) Occult hemorrhage in children with severe ITP. Am J Hematol 91(3):287–290CrossRefGoogle Scholar
  3. 3.
    Goel N, Arora S, Jain P, Ghosh B (2014) Massive subretinal and vitreous haemorrhages at presentation in idiopathic thrombocytopenic purpura: report of a case and review of literature. Clin Exp Optom 97(3):270–273CrossRefGoogle Scholar
  4. 4.
    Harrington WJ, Minnich V, Hollingworth JW, Moore CV (1951) Demonstrating of a thrombocytopenic factor in the blood of patients with thrombocytopenic purpura. J Lab Clin Med 38(1):1–10Google Scholar
  5. 5.
    Holt JM, Gordon-Smith EC (1969) Retinal abnormalities in diseases of the blood. Br J Ophthalmol 53:145–160CrossRefGoogle Scholar
  6. 6.
    Kühne T, Berchtold W, Michaels LA, Wu R, Donato H, Espina B, Tamary H, Rodeghiero F, Chitlur M, Rischewski J, Imbach P, Intercontinental Cooperative ITP Study Group (2011) Newly diagnosed immune thrombocytopenia in children and adults: a comparative prospective observational registry of the intercontinental cooperative immune thrombocytopenia study group. Haematologica 96:1831–1837CrossRefGoogle Scholar
  7. 7.
    Mansour AM, Lee JW, Yahng SA, Kim KS, Shahin M (2014) Ocular manifestations of ideopathic aplastic anemia: retrospective study and literature review. Clin Ophtalmol 17(8):777–787CrossRefGoogle Scholar
  8. 8.
    Neunert C, Lim W, Crowther M, Cohen A, Solberg L Jr, Crowther MA; American Society of Hematology. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 Apr 21;117(16):4190–4207Google Scholar
  9. 9.
    Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB (2010) International consensus report the investigation and management of primary immune thrombocytopenia. Blood 115(2):168–186CrossRefGoogle Scholar
  10. 10.
    Rosthøj S, Hedlund-Treutiger I, Rajantie J, Zeller B, Jonsson OG, Elinder G, Wesenberg F, Henter JI, NOPHO ITP Working Group (2003) Duration and morbidity of newly diagnosed idiopathic thrombocytopenic purpura in children: a prospective Nordic study of an unselected cohort. J Pediatr 143:302–307CrossRefGoogle Scholar
  11. 11.
    World Health Organization, UNICEF&United Nations University (1998) Iron Deficiency: indicators for Assessment and Strategies for Prevention.WHO,Geneva,SwitzerlandGoogle Scholar
  12. 12.
    Zeller B, Rajantie J, Hedlund-Treutiger I, Tedgård U, Wesenberg F, Jonsson OG, Henter JI, NOPHO ITP (2005) Childhood idiopathic thrombocytopenic purpura in the Nordic countries: epidemiology and predictors of chronic disease. Acta Paediatr 94:178–184CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Pediatric Emergency Medicine, Dana-Dwek Children’s HospitalTel Aviv Sourasky Medical CenterTel-AvivIsrael
  2. 2.Sackler School of MedicineTel-Aviv UniversityTel-AvivIsrael
  3. 3.Pediatric Hemato-oncology Department, Dana-Dwek Children’s HospitalTel Aviv Sourasky Medical CenterTel AvivIsrael

Personalised recommendations