India’s haemophilia diagnosis gap has an overlooked consequence: preventable vision loss

Haemophilia, a genetic bleeding disorder where blood doesn’t clot properly, is usually hereditary and can be passed down from parent to child. The condition is caused by a lack of, or improper functioning of certain clotting factors. This can lead to uncontrolled bleeding after injuries, or even without a clear trigger.

India has the world’s second-largest haemophilia burden. A 2025 review in the Journal of the Association of Physicians of India put prevalence of diagnosed and registered haemophilia cases in India at 0.9 per 1,00,000. However, statistical modelling puts the true disease burden much higher, at around 1,36,000.

Diagnostic challenges

The challenge is to reach those who have not been formally diagnosed. Low awareness and the concentration of labs that can diagnose haemophilia in a handful of metros are some of the reasons for the gap in both timely diagnosis and access to care.

Usually when this gap is discussed, the focus is on the orthopaedic impact on patients – repeated joint bleeds, arthropathy, a young man with the knees of a seventy-year-old. While this is an important aspect of the condition, it leads to lesser conversations on the other effects of haemophilia on the body – the effect on the eyes and vision. This is irreversible when it happens, and can cost patients with undiagnosed haemophilia their sight.

The vision problem

A retrospective study of haemophilia patients at a government hospital in India found that bleeding in and around the eye accounted for 13% of all bleeds recorded. The types of bleeding included anterior segment bleeding (part of the eye in front of the lens), subconjunctival haemorrhage (under the conjunctiva), periorbital ecchymoses (bruising of the skin around the eye), and hyphaema (pooling of blood inside the front chamber of the eye). Posterior segment bleeding in the part of eye behind the lens occurred in around 1.8% of patients. This is a critical matter and led to permanent loss of vision in the affected eye.

The onset can be sudden. One of the patients in the study was a 45-year-old man with moderate haemophilia and no other illness. He came with a sudden one-sided headache. There was no eye pain and no injury that would have made him consult an ophthalmologist. The headache was eventually attributed to an intraorbital haemorrhage, by which point the eye was lost.

That is the challenge faced. While bleeding that threatens vision is a rare occurrence in the eye, the diagnosis is usually delayed due to ambiguous symptoms, with a very short window to take action and correct the clotting factor levels in the blood.

Missing elements

A common scenario is a patient with undiagnosed haemophilia being taken into an operating theatre in an emergency. Traumatic hyphaema or pooling of blood inside the front chamber of the eye due to an injury is quite common in a child. The usual pre-operative panel that includes a complete blood count, a chest radiograph and a urinalysis, does not detect a clotting factor deficiency. In such a case, surgery may result in bleeding in the eye after the procedure, with resultant complications.

Two more factors make the risk harder to tackle. About a third of people born with haemophilia have no family history at all, so an unremarkable family tree is not reassurance. And mild haemophilia frequently goes undetected until adulthood, surfacing only after a dental extraction, an accident or surgery.

The clinical baselines are well established. For ocular surgery, clotting factor levels are recommended at 70% to 80%, with a minimum of 50% in emergencies. Blood in the anterior chamber or vitreous is treated as an emergency requiring immediate treatment. None of this is achievable if the diagnosis is unknown, and is difficult if the clotting factors are not readily available.

The solution

This can be fixed. Pre-operative checklists must have a bleeding history line that asks specifically about prolonged bleeding after tooth extraction, easy bruising and heavy menstrual periods. An APTT (Activated Partial Thromboplastin Time) and factor assay must be done whenever ocular bleeding looks disproportionate to the trauma that caused it. Referral links between district eye units and the nearest haemophilia treatment centre must be established.

Damage to joints takes place over years and can be partly rehabilitated. An eye does not get a second chance. We must work to prevent vision loss due to India’s haemophilia diagnosis gap.

(Dr. Anusha Venkataraman is senior consultant & surgeon – vitreo retina and ocular oncology, ASG Vasan Eye Care, Coimbatore. anushavenkat262@gmail.com)