Grand Rounds Purtscher’s Retinopathy. Mark A. Ihnen, M.D. University of Louisville Department of Ophthalmology and Visual Sciences 4 /4/2014. Presentation. CC : “ I can’t make out faces with my right eye. ” - PowerPoint PPT Presentation
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Grand RoundsMark A. Ihnen, M.D.
4/4/2014
1
Presentation
CC: “I can’t make out faces with my right eye.”
HPI: 40 WM c/o blurred central vision OD after being struck by a
car while changing a flat tire on an interstate off-ramp. The
patient also sustained multiple rib fractures/pneumothorax and a
laceration to the left ear. Transported to UL Emergency
Department.
2
Presentation
IOP: WNL OU
EOM: Full OU
Clinical Photos
Fundus video OD demonstrating large peripapillary cotton-wool spots
and superficial hemorrhages.
Inpatient Clinical Course
Patient’s left ear was surgically repaired
Thoracostomy tube was removed, stable for discharge.
Arranged to follow-up on the day of discharge in our Retina
Clinic.
Dilated Fundus Exam: Clinic Photos
Color fundus photo of the right eye demonstrating multiple, large,
peripapillary, cotton-wool spots and superficial hemorrhages. Note
the intervening clear zones between each CWS sparing vessels.
Dilated Fundus Exam: Clinic Photos
Color fundus photo of the left eye: Normal.
HVF 24-2 OU
OS
OD
OCT image of right eye demonstrating elevation corresponding to
large superficial cotton wool spot.
SD-OCT (OS)
OCT image of the left eye demonstrating normal foveal
contour.
FA of OD
Mid phase FA of right eye demonstrating multiple areas of
hypofluorescence corresponding to large CWS.
FA of OD
Late phase FA of right eye demonstrating multiple areas of
hypofluorescence corresponding to large CWS with small amount of
late leakage.
FA of OS
Assessment and Plan
40 WM presenting with central scotoma OD and multiple peripapillary
CWS following a thoracic compression injury.
DDX:
Lost to follow-up.
Purtscher’s Retinopathy
First described by Dr. Othmar Purtscher (1852–1927) in 1910.
Originally observed in two severely traumatized patients with head
injuries.
Fully described in a publication in 1912 by Dr. Purtscher.
True Purtscher's retinopathy, as first described, is always
associated with a traumatic injury.
When there is a non-traumatic etiology the correct designation is
Purtscher-like retinopathy.
http://www.mrcophth.com/ophthalmologyhalloffame/purtscher.html
Clinical Presentation
Patients present with decreased visual acuity, often sudden
(usually within 48 hours) and severe (20/200 or worse)
History of compression injury to chest, head or long bone fracture
(fat embolism syndrome)
Fundoscopic signs include peripapillary cotton wool spots and/or
superficial hemorrhages in over 92% of cases.
Purtscher flecken are considered pathognomic, but only occur in 50%
of cases.
Typically bilateral but many times unilateral.
Purtscher-like Retinopathy
Associations include:
Acute pancreatitis
Indication of multiorgan failure and is often associated with a
fatal outcome
Chronic renal failure
Childbirth (amniotic fluid embolism)
For trauma-related cases, the diagnosis is clinically apparent
after fundus examination and no further workup is required.
However, cases without trauma or causative medical condition
require a comprehensive medical evaluation in conjunction with an
internist.
Purtscher’s Retinopathy
Pathogenesis
Thought to be a result of injury-induced complement activation,
which causes granulocyte aggregation and leukoembolization.
This process in turn occludes small arterioles such as those found
in the peripapillary retina.
Treatment
Anecdotal reports of limited success with high dose systemic
corticosteroids.
Purtscher’s Retinopathy
Although retinal whitening and hemorrhages slowly disappear over
weeks to months, usually no significant recovery of vision
occurs.
Systematic Review
Mean visual acuity 20/200, range of 20/20 to LP.
Trauma and acute pancreatitis were the most frequent
etiologies.
There was no statistically significant difference in VA improvement
for patients treated with corticosteroids compared with
observation.
Trauma and pancreatitis were associated with higher probability of
visual improvement.
Case report : 24 WF with post partum Purtscher- like retinopathy
treated with sub-tenon triamcinolone
Presenting VA 20/200 OD 5 week follow-up: VA 20/60
Oral Indomethacin 25 mg/day for six weeks
43 WM with Purtscher’s like retinopathy associated with valsalva
maneuver:
Presenting VA CF OS
Thank You
Atabay C, et al. Late visual recovery after intravenous
methylprednisolone treatment of Purtscher's retinopathy. Ann
Ophthalmol. 1993;25(9):330-333.
Behrens-Baumann W, Scheurer G, Schroer H. Pathogenesis of
Purtscher's retinopathy. Graefes Arch Clin Exp Ophthalmol.
1992;230(3):286-291
Purtscher O. Ber Deutsche Ophth Ges 1910;36:294-301.
Jacob HS, Craddock PR, Hammerschmidt DE, Moldow CF.
Complement-induced granulocyte aggregation: an unsuspected
mechanism of disease. N Eng J Med. 1980;302:789-794.
Purtscher O. Angiopathia retinae traumatica. Lymphorrhagien des
Augengrunes. Albrecht Von Graefes Arch Ophthalmol.
1912;82:347-371.
Scheurer G, Praetorius G, Damerau B, Behrens-Baumann W. Vascular
occlusion of the retina: an experimental model. I. Leukocyte
aggregates. Graefes Arch Clin Exp Ophthalmol. 1992;
230(3):275-280.
Maassen J, Oetting T. Purtscher's Retinopathy: 22-year-old male
with vision loss after trauma. EyeRounds.org. May 18, 2005
BCSC: Retina and Vitreous: Purtscher’s Retinopathy: 105-106