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Case Description
• ID • 25 year old man with history of alcohol abuse
presented with acute necrotizing pancreatitis.
• HPI • Acute onset of epigastric pain, nausea, vomiting
and elevated lipase. • Development of pseudocyst, paracolic fluid, pleural
effusion, mild pericardial effusion, acute tubular necrosis requiring hemodialysis.
• ROS • Blurry vision and decreased ability to see faces
with onset of abdominal pain.
• PE • OD 20/160, OS 20/250 • Dilated fundus exam: cotton wool spots,
peripapillary hemorrhages, and mild macular edema
• Hospital Course • Developed hemorrhagic phlegmon and PEA arrest
following blood transfusion. • Pancreatitis resolved and discharged after two
months hospital stay with continued outpatient hemodialysis.
• No further documentation regarding vision changes or improvements noted prior to discharge.
Discussion
• Epidemiology
• 0.24 persons per 1 million • Up to 10 percent of acute pancreatitis
• Pathogenesis • Complement activation embolic phenomena
vascular occlusion of retinal arterioles
• Clinical and Objective findings • Asymptomatic to significant visual loss • “Purtscher flecken”, cotton wool spots, retinal
hemorrhages or macular edema
• Management • Supportive approach initially • Limited data support IV and then PO steroids
• Lessons • Recognize and diagnose rare complication
associated with pancreatitis • Provide counseling for potentially distressing
symptom • Role for medical treatment if no spontaneous
resolution
• Recognize Purtscher Retinopathy as an uncommon complication of acute pancreatitis.
• Understand the epidemiology, pathogenesis, clinical findings and management of Purtscher Retinopathy.
Learning Objectives
References
Images
Purtscher Retinopathy: An Eye On Acute Pancreatitis
1) Mayer C, Khoramnia R. Purtscher‐like re;nopathy caused by acute pancrea;;s Lancet 2011; 378: 1653 2) Carrera CR, Pierre LM, Medina FM, Pierre‐Filho Pde T. Purtscher‐like re;nopathy associated with acute pancrea;;s. Sao Paulo Med J. 2005 Nov 3;123(6):289‐91. 3) Agrawal A, McKibbin M. Purtscher's re;nopathy: epidemiology, clinical features and outcome. Br J Ophthalmol. 2007 Nov;91(11):1456‐9. 4) Bhan K, Ashiq A, AralikaZ A, Menon KV, McKibbin M. The incidence of Purtscher re;nopathy in acute pancrea;;s. Br J Ophthalmol. 2008 Jan;92(1):151‐3 5) Agrawal A, McKibbin MA. Purtscher's and Purtscher‐like re;nopathies: a review. Surv Ophthalmol. 2006 Mar‐Apr;51(2):129‐36. 6) Shapiro I, Jacob HS. Leukoemboliza;on in ocular vascular occlusion. Ann Ophthalmol. 1982 Jan;14(1):60‐2 7) Holak HM, Holak S. Prognos;c factors for visual outcome in purtscher re;nopathy.Surv Ophthalmo. 2007 Jan‐Feb;52(1):117‐8; author reply 118‐9.
Tin Nguyen MD1; Eleanor Loomis MD, MPH2; Raja Jagadeesan MD, MS, MPH2,3
Family Medicine1 and Internal Medicine2 Residency Programs, UC Davis School of Medicine Sacramento VA Hospital3
Purtscher Retinopathy: Uncommonly Recognized Complication of Acute Pancreatitis
Figure 1 and 2: Bilateral dilated fundoscopic exam illustrating cotton wool spots, peripapillary
hemorrhages and mild macular edema consistent with Purtscher Retinopathy.
Figure 1 Figure 2
Commonly Recognized Complications of Acute Pancreatitis
Figure 3: Acute Walled Off Necrotic
Fluid Collections
Figure 4: Hemorrhagic Phlegmon
Figure 5: CT – Pleural Effusion Figure 6: CXR -Pleural Effusion