Delhi Journal of Ophthalmology

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Purtscher’s Retinopathy

Anil Kumar Verma, Rajeev Tuli, Gaurav Sharma, Deepak Sharma
Department of Ophthalmology
Dr RPG Medical College,
Tanda, Himachal Pradesh, India

Corresponding Author:

Anil Kumar Verma
Department of Ophthalmology
Dr R P G Medical College, Tanda, Himachal Pradesh, India
Email: anilkumarverma2971@gmail.com

Published Online: 01-DEC-2014
DOI:http://dx.doi.org/10.7869/djo.92

Abstract
Purtscher’s retinopathy, a indirect ocular injury, presents with multiple patches of superficial retinal whitening and retinal hemorrhages surrounding the optic nerve. The optic disc may appear normal initially but an afferent pupillary defect may be present and later on  optic disc pallor may develop. Two similar cases of Purtscher’s retinopathy with fundus photographs are being reported in this article.
Keywords :purtscher’s fleckens • retnal whitening • relative afferent papillary defect (RAPD) • best corrected visual acuity (BCVA)

We report two cases of bilateral Purtscher’s retinopathy in young men aged 27 & 25 years of age, following road side accidents. Both patients sustained multiple injuries while they were driving and met with road side accident leading to rolling down of their vehicles by the side of the hill. Both patients had severe impairment of vision in right eye with relative afferent papillary defect (RAPD) within two days of accident. Both patients had Purtscher’s flecken with intra retinal hemorrhages around optic nerve head in both eyes. Right eye in both patients had severe involvement.

Case Report

Case-1

A 27 year old male reported in the emergency department with the history of road side accident while driving his vehicle. His vehicle rolled down by the side of the hill. He sustained multiple injuries i.e. fracture body of D1 vertebra, fracture of left transverse processes of D11,, D12, L1,, L2, & L3 vertebrae and laceration over posterior aspect of scalp. There was no injury to the optic nerve on CT scan. He complained of loss of vision in the right eye. On examination there was relative afferent papillary defect (RAPD) on the right side. The BCVA in the right eye was finger counting at distance of one feet & in the left eye vision was 6/6. No significant abnormality was seen in the anterior segment on slit lamp examination. Dilated fundus examination showed confluent retinal whitening or Purtcher’s fleckens with multiple retinal hemorrhages around the optic disc in the right eye (Figure-1). In the left eye there were few Purtscher’s fleckens around the optic disc (Figure-2). Patient was put on oral prednisolone 1 mg/Kg OD after breakfast along with Omeprazole 20mg empty stomach. On 4th day his vision improved to 6/60 in the right eye. At two month follow up fundus examination revealed that although retinal whitening and retinal hemorrhages had decreased in both eyes but optic disc pallor had developed in the right eye. But the BCVA had improved to 6/36 in the right eye & in the left eye vision was 6/6. Oral prednisolone was tapered over a period of 4 weeks. At 5 month follow up it was found that all the cotton wool spots and retinal hemorrhages had resolved completely in both eyes (Figure - 3 & 4) with improvement of BCVA to 6/12 in the right eye. But there was optic disc pallor in the right eye along with RAPD (Figure-3).

Case-2

A 25 year old male was brought into the emergency department with the similar history of road side accident as case -1, while driving his vehicle & he along with the vehicle rolled down the side of the hill. He sustained multiple injuries i.e. fracture right frontal bone with laceration over right side of scalp and face, fracture of both clavicles at the junction of lateral 1/3rd and medial 2/3rd and fracture of 6th and 7th rib on the right side. There was no injury to the optic nerve on CT Scan. Patient complained of loss of vision in the right eye. On examination relative afferent pupillary defect (RAPD) was detected in the right eye. Vision in the right eye was Hand movements (HM) and in left eye was 6/6 on third day of the accident. He had subconjunctival hemorrhage bilaterally but no other significant abnormality in the anterior segment. On dilated fundus examination findings were more severe in the right eye. Multiple areas of retinal whitening with retinal hemorrhage was seen around optic disc in the right eye and few cotton wool spots (Figure-5) and one retinal hemorrhage was seen in the left eye around optic disc (Figure-6). Patient was put on oral steroid prednisolone 1mg/kg body wt/day for one month ,& was tapered for another on month. Patient was followed up for 5 months. Within this period all Purtscher’s fleckens and retinal hemorrhages had resolved in both eyes (Figure 7 & 8) and BCVA had improved to 6/12 in right eye. But optic disc had developed pallor in the right eye and RAPD was present (Figure-7).

















Conclusion

Purtscher’s retinopathy (traumatic retinal angiopathy frequently following head or chest injuries) should be considered as a differential diagnosis in cases where visual loss is associated with multiple traumas. Purtscher’s retinopathy was first described by Otmar Purtscher an Austrian Ophthalmologist in 1910. Purtscher encountered a case of traumatic retinopathy following head trauma which was associated with vision loss.[7] He later referred to as ‘angiopathia retinae traumatica’.[3] Purtscher’s retinopathy is classically recognized as retinal manifestation of mechanical trauma occurring elsewhere in the body and presents as an acute visual loss. However the retinal signs are transient. If the diagnosis is initially missed, the correct diagnosis can only be inferred retrospectively, and only after exclusion of the direct mechanisms like head injury associated with damage to visual projection or traumatic optic neuropathy secondary to skull fracture involving the optic canal, by costly and unnecessary neuroimaging.[4] The characteristic of the retinal findings are multiple patches of superficial retinal whitening and retinal hemorrhages surrounding the optic nerve. The disc may appear normal initially (Figure 1 & 5). But an afferent papillary defect may be present and later optic disc pallor (Figure 3 & 7) may develop.[1] The characteristics of of retinopathy are ischemic spots and hemorrhages in the peri-papillary region and the macular area up to the mid periphery.[5] Due to the peculiar anatomy of blood supply of peripapillary retina and macular area, the retinal changes are usually confined to these areas. The arterioles and capillaries in these areas are more susceptible to embolic occlusion as a result of fewer arteriolar feeders and fewer anastomosis.[6] In both our cases right eye ( Figure 1 & 5) was involved more than the left eye (Figure 2 & 6) which probably reflects the greater possibility of emboli travelling to the right carotid artery because of its anatomical difference from left common carotid artery.[10] The characteristic findings in the fundus are Purtscher flecken, which are multiple cotton wool spots of varying sizes. The retinal whitening and hemorrhages resolve over several months, although the patient may be left with some loss of vision secondary to pigmentary macular changes and optic atrophy[1]. In majority of the patients recovery of useful vision to 6/12 or better is expected however if macular arterioles are involved, the prognosis is generally poor. Purtscher like retinopathy was observed to be associated with a variety of non traumatic systemic diseases such as acute pancreatitis, systemic lupus erythematosus, thrombotic thrombocytopenic purpura and chronic renal failure.[2]

There are no specific recommended guide lines for treatment of patients with Purtscher’s Retinopathy. Saidin Nor-Mosniwati et al[9] reported a case who was treated with indomethacin tablets 25 mg daily for six weeks and his vision improved from finger counting at presentation to 6/12. Wang et al. reported a case of patient who was given a mega dose of steroid that showed a good visual response with in first two weeks of treatment.[8] Yu-Chi-Lin et al. reported a case of chest contusion who was treated with multiple sessions of hyperbaric oxygen therapy at 2 atm for 90 minutes given twice a day, for 39 courses, which led to gradual improvement of visual function and retinal appearance.[7] We treated our both patients with oral steroids Tablet Prednisolone 1 mg / Kg body weight for one month and later on tapered for next four weeks . The visual acuity in right eye improved to 6/12 in both the cases on follow up at 5months .But optic disc had developed partially pallor and there was RAPD in the right eye in both the cases. The vision in the left eye of both the patients was 6/6 at the time of presentation and follow up after five months. Physicians, especially those involved in trauma care should be aware of possibility of the development of this potentially blinding condition even in cases with no evidence of direct ocular trauma[6]. Patients brought to the emergency department with multiple trauma should have a complete eye examination including dilated fundus examination, as patients with a mild degree of visual impairment may not be detected[3]. Early detection, proper documentation and treatment of the underlying causes are very important in order to avoid medico-legal pitfalls.[6]

Financial & competing interest disclosure

The authors do not have any competing interests in any product/procedure mentioned in this study. The authors do not have any financial interests in any product / procedure mentioned

References
  1. Mark W.Balles. Traumatic Retinopathy. In: Principles and Practice of Ophthalmology, Second Edition, W.B. Saunders company; Phyladelphia, Pennsylvania; 2000. P. 2221-25.
  2. Jason Hsu and Carl D. Regillo. Distant Trauma with Posterior Segment Effects. In: Yanoff & Duker Ophthalmology, Third Edition, Mosby Elsevier; UK; 2009. P. 750-54.
  3. Roy C. Watkins, Edith L. Hambrick, Miriam Martin, Michael Washington. J Nati Med Assoc.1993; 85:557-59.
  4. Ling R, Beigi B. Iranian Journal of Ophthalmology 2006; 19:51-56.
  5. W. Beherens-Baumann, G.Scheurer, H.Schroer.  Graefe’s Arch Clin Expo Ophthalmol 1992; 230:286-91.
  6. Hashim S P, Shafei M M El, Ansari Z M Al. Journal of Emergency Medicine Trauma & Acute Care. 2012; 9.
  7. Lin Y C, Yang C M, Lin C L. Hyperbaric Oxygen Treatment in Purtscher Retinopathy Induced by Chest Injury.2006; 69: P.444-48.
  8. Wang AG, Yen MY, Liu JH. Pathogenesis and Neuroprotective treatment in Purtscher’s Retinopathy. Japan journal of Ophthalmology 1998; 42:318-22.
  9. Nor-Masniwati S, Azhany Y, Zunaina. Purtscher-like Retinopathy following valsalva maneuver effect: Case report. Journal of Medical Case Reports. 2011; 5:338.
  10. Sanborn GE, MagargalLE.Arterial obstructive disease of the eye. In: Tasman WS, Jaegar EA, eds. Clinical ophthalmology, Vol 3. Philadelphia: Lippincott; 1993:14: 1-29.

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Verma AK, Tuli R, Sharma G, Sharma DPurtscher’s Retinopathy.DJO 2014;25:125-128

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Verma AK, Tuli R, Sharma G, Sharma DPurtscher’s Retinopathy.DJO [serial online] 2014[cited 2019 Aug 22];25:125-128. Available from: http://www.djo.org.in/articles/25/2/purtschers-retinopathy.html