Grand Rounds Purtschers Retinopathy Mark A. Ihnen, M.D.
University of Louisville Department of Ophthalmology and Visual
Sciences 4/4/2014
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Presentation CC: I cant 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.
Exam OD OS OD OS BCVA: 20/200 20/20 Pupils: 4 2 OU, no APD IOP:
WNL OU EOM: Full OU Anterior Exam: Extensive subconjunctival
hemorrhage OU, otherwise WNL
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Clinical Photos
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Dilated Fundus Exam at Bedside Fundus video OD demonstrating
large peripapillary cotton-wool spots and superficial
hemorrhages.
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Inpatient Clinical Course Patients left ear was surgically
repaired Patients left ear was surgically repaired Thoracostomy
tube was removed, stable for discharge. Thoracostomy tube was
removed, stable for discharge. Arranged to follow-up on the day of
discharge in our Retina Clinic. Arranged to follow-up on the day of
discharge in our Retina Clinic.
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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.
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Dilated Fundus Exam: Clinic Photos Color fundus photo of the
left eye: Normal.
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HVF 24-2 OU HVF 24-2: Left eye: Full; Right Eye: Central
scotoma. OSOD
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SD-OCT (OD) OCT image of right eye demonstrating elevation
corresponding to large superficial cotton wool spot.
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SD-OCT (OS) OCT image of the left eye demonstrating normal
foveal contour.
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FA of OD Mid phase FA of right eye demonstrating multiple areas
of hypofluorescence corresponding to large CWS.
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FA of OD Late phase FA of right eye demonstrating multiple
areas of hypofluorescence corresponding to large CWS with small
amount of late leakage.
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FA of OS Mid phase FA of left eye within normal limits.
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Assessment and Plan 40 WM presenting with central scotoma OD
and multiple peripapillary CWS following a thoracic compression
injury. 40 WM presenting with central scotoma OD and multiple
peripapillary CWS following a thoracic compression injury. DDX:
DDX: Purtschers Retinopathy Purtschers Retinopathy Commotio Retinae
Commotio Retinae Plan: Plan: Intravitreal Kenalog Injection
Intravitreal Kenalog Injection
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Clinical Course Patient initially refused IVK injection and
then reconsidered. Patient initially refused IVK injection and then
reconsidered. Lost to follow-up. Lost to follow-up.
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Purtschers Retinopathy Introduction Introduction First
described by Dr. Othmar Purtscher (18521927) in 1910. First
described by Dr. Othmar Purtscher (18521927) in 1910. Originally
observed in two severely traumatized patients with head injuries.
Originally observed in two severely traumatized patients with head
injuries. Fully described in a publication in 1912 by Dr.
Purtscher. Fully described in a publication in 1912 by Dr.
Purtscher. True Purtscher's retinopathy, as first described, is
always associated with a traumatic injury. 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. When there is a
non-traumatic etiology the correct designation is Purtscher-like
retinopathy.
http://www.mrcophth.com/ophthalmologyhalloffame/purtscher.html
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Purtschers Retinopathy Epidemiology Epidemiology Incidence of
0.24 persons per million per year Incidence of 0.24 persons per
million per year Clinical Presentation Clinical Presentation
Patients present with decreased visual acuity, often sudden
(usually within 48 hours) and severe (20/200 or worse) 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)
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. 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.
Purtscher flecken are considered pathognomic, but only occur in 50%
of cases. Typically bilateral but many times unilateral. Typically
bilateral but many times unilateral.
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Purtscher-like Retinopathy Purtscher-like retinopathy: not
associated with trauma. Purtscher-like retinopathy: not associated
with trauma. Associations include: Associations include: Acute
pancreatitis Acute pancreatitis Indication of multiorgan failure
and is often associated with a fatal outcome Indication of
multiorgan failure and is often associated with a fatal outcome
Chronic renal failure Chronic renal failure Autoimmune Disease
Autoimmune Disease SLE, scleroderma, dermatomyositis, Sjogren
syndrome SLE, scleroderma, dermatomyositis, Sjogren syndrome
Childbirth (amniotic fluid embolism) Childbirth (amniotic fluid
embolism) Retrobulbar anesthesia Retrobulbar anesthesia Valsalva
maneuver Valsalva maneuver
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Purtschers Retinopathy Diagnosis Diagnosis For trauma-related
cases, the diagnosis is clinically apparent after fundus
examination and no further workup is required. 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.
However, cases without trauma or causative medical condition
require a comprehensive medical evaluation in conjunction with an
internist.
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Purtschers Retinopathy Pathogenesis Pathogenesis Thought to be
a result of injury-induced complement activation, which causes
granulocyte aggregation and leukoembolization. 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. This process in turn occludes small arterioles such as
those found in the peripapillary retina. Treatment Treatment No
known effective treatment exists. No known effective treatment
exists. Anecdotal reports of limited success with high dose
systemic corticosteroids. Anecdotal reports of limited success with
high dose systemic corticosteroids.
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Purtschers Retinopathy Prognosis Prognosis Although retinal
whitening and hemorrhages slowly disappear over weeks to months,
usually no significant recovery of vision occurs. Although retinal
whitening and hemorrhages slowly disappear over weeks to months,
usually no significant recovery of vision occurs.
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Systematic Review Systematic Review Mean visual acuity 20/200,
range of 20/20 to LP. Mean visual acuity 20/200, range of 20/20 to
LP. Trauma and acute pancreatitis were the most frequent
etiologies. 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. 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. Trauma and pancreatitis
were associated with higher probability of visual improvement.
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Case report : 24 WF with post partum Purtscher- like
retinopathy treated with sub-tenon triamcinolone 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 Presenting VA 20/200 OD 5 week follow-up: VA 20/60
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Oral Indomethacin 25 mg/day for six weeks Oral Indomethacin 25
mg/day for six weeks 43 WM with Purtschers like retinopathy
associated with valsalva maneuver: 43 WM with Purtschers like
retinopathy associated with valsalva maneuver: Presenting VA CF OS
6 week followup VA 20/40 OS
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Thank You
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References 1. Atabay C, et al. Late visual recovery after
intravenous methylprednisolone treatment of Purtscher's
retinopathy. Ann Ophthalmol. 1993;25(9):330-333. 2.Behrens-Baumann
W, Scheurer G, Schroer H. Pathogenesis of Purtscher's retinopathy.
Graefes Arch Clin Exp Ophthalmol. 1992;230(3):286-291 3.Purtscher
O. Ber Deutsche Ophth Ges 1910;36:294-301. 4.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. 5.Purtscher O. Angiopathia retinae traumatica.
Lymphorrhagien des Augengrunes. Albrecht Von Graefes Arch
Ophthalmol. 1912;82:347-371. 6.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. 7.Maassen J, Oetting T.
Purtscher's Retinopathy: 22-year-old male with vision loss after
trauma. EyeRounds.org. May 18, 2005 8.BCSC: Retina and Vitreous:
Purtschers Retinopathy: 105-106 9.Hsu J, Regillo CD. Distant Trauma
with Posterior Segment Effects. Yanoff and Duker: Ophthalmolgoy 3
rd ed. Ch 6.43: 751-752.
