Grand Rounds Purtscher

1
Grand RoundsPurtschers Retinopathy

• Mark A. Ihnen, M.D.
• University of Louisville
• Department of Ophthalmology and Visual Sciences
• 4/4/2014

2
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.

3
Presentation

• POH None
• PMH None
• Meds None
• Allergies None

4
Exam

• 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

5
Clinical Photos
6
Dilated Fundus Exam at Bedside
Fundus video OD demonstrating large peripapillary
cotton-wool spots and superficial hemorrhages.
7
Inpatient Clinical Course

• Patients 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.

8
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.
9
Dilated Fundus Exam Clinic Photos
Color fundus photo of the left eye Normal.
10
HVF 24-2 OU
OS
OD
HVF 24-2 Left eye Full Right Eye Central
scotoma.
11
SD-OCT (OD)
OCT image of right eye demonstrating elevation
corresponding to large superficial cotton wool
spot.
12
SD-OCT (OS)
OCT image of the left eye demonstrating normal
foveal contour.
13
FA of OD
Mid phase FA of right eye demonstrating multiple
areas of hypofluorescence corresponding to large
CWS.
14
FA of OD
Late phase FA of right eye demonstrating multiple
areas of hypofluorescence corresponding to large
CWS with small amount of late leakage.
15
FA of OS
Mid phase FA of left eye within normal limits.
16
Assessment and Plan

• 40 WM presenting with central scotoma OD and
  multiple peripapillary CWS following a thoracic
  compression injury.
• DDX
• Purtschers Retinopathy
• Commotio Retinae
• Plan
• Intravitreal Kenalog Injection

17
Clinical Course

• Patient initially refused IVK injection and then
  reconsidered.
• Lost to follow-up.

18
Purtschers Retinopathy

• Introduction
• First described by Dr. Othmar Purtscher
  (18521927) 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/pu
rtscher.html
19
Purtschers Retinopathy

• Epidemiology
• Incidence of 0.24 persons per million per year
• 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.

20
Purtscher-like Retinopathy

• Purtscher-like retinopathy not associated with
  trauma.
• Associations include
• Acute pancreatitis
• Indication of multiorgan failure and is often
  associated with a fatal outcome
• Chronic renal failure
• Autoimmune Disease
• SLE, scleroderma, dermatomyositis, Sjogren
  syndrome
• Childbirth (amniotic fluid embolism)
• Retrobulbar anesthesia
• Valsalva maneuver

21
Purtschers Retinopathy

• Diagnosis
• 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.

22
Purtschers 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
• No known effective treatment exists.
• Anecdotal reports of limited success with high
  dose systemic corticosteroids.

23
Purtschers Retinopathy

• Prognosis
• Although retinal whitening and hemorrhages slowly
  disappear over weeks to months, usually no
  significant recovery of vision occurs.

24

• 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.

25

• 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

26

• Oral Indomethacin 25 mg/day for six weeks
• 43 WM with Purtschers like retinopathy
  associated with valsalva maneuver
• Presenting VA CF OS
• 6 week followup VA 20/40 OS

27
Thank You
28
References

• Atabay C, et al. Late visual recovery after
  intravenous methylprednisolone treatment of
  Purtscher's retinopathy. Ann Ophthalmol.
  199325(9)330-333.
• Behrens-Baumann W, Scheurer G, Schroer H.
  Pathogenesis of Purtscher's retinopathy. Graefes
  Arch Clin Exp Ophthalmol. 1992230(3)286-291
• Purtscher O. Ber Deutsche Ophth Ges
  191036294-301.
• Jacob HS, Craddock PR, Hammerschmidt DE, Moldow
  CF. Complement-induced granulocyte aggregation
  an unsuspected mechanism of disease. N Eng J Med.
  1980302789-794.
• Purtscher O. Angiopathia retinae traumatica.
  Lymphorrhagien des Augengrunes. Albrecht Von
  Graefes Arch Ophthalmol. 191282347-371.
• 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 Purtschers
  Retinopathy 105-106
• Hsu J, Regillo CD. Distant Trauma with Posterior
  Segment Effects. Yanoff and Duker Ophthalmolgoy
  3rd ed. Ch 6.43 751-752.