Transcript Purtschers - University of Louisville Department of Ophthalmology

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.”
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.
Presentation
POH: None
PMH: None
Meds: None
Allergies: None
Exam
BCVA:
OD
20/200
OS
20/20
Pupils: 4  2 OU, no APD
IOP: WNL OU
EOM: Full OU
Anterior Exam: Extensive subconjunctival
hemorrhage OU, otherwise WNL
Clinical Photos
Dilated Fundus Exam at Bedside
Fundus video OD
demonstrating
large peripapillary
cotton-wool spots
and superficial
hemorrhages.
Inpatient Clinical Course
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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
HVF 24-2: Left eye: Full; Right Eye: Central scotoma.
OD
SD-OCT (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
Mid phase FA of left eye within normal limits.
Assessment and Plan
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40 WM presenting with central scotoma OD and
multiple peripapillary CWS following a thoracic
compression injury.
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DDX:
Purtscher’s Retinopathy
 Commotio Retinae
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Plan:
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Intravitreal Kenalog Injection
Clinical Course
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Patient initially refused IVK injection and then
reconsidered.
Lost to follow-up.
Purtscher’s Retinopathy
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Introduction
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.
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http://www.mrcophth.com/ophthalmologyhalloffame/purtscher.html
Purtscher’s Retinopathy
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Epidemiology
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Incidence of 0.24 persons per million per year
Clinical Presentation
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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
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Purtscher-like retinopathy: not associated with
trauma.
Associations include:
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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
Purtscher’s Retinopathy
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Diagnosis
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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
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Pathogenesis
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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
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No known effective treatment exists.
Anecdotal reports of limited success with high dose systemic
corticosteroids.
Purtscher’s Retinopathy
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Prognosis
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Although retinal whitening and hemorrhages slowly disappear
over weeks to months, usually no significant recovery of
vision occurs.
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Systematic Review
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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.
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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
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Oral Indomethacin 25 mg/day for six weeks
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43 WM with Purtscher’s like retinopathy associated with valsalva
maneuver:
Presenting VA CF OS
6 week follow–up VA 20/40 OS
Thank You
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: Purtscher’s Retinopathy: 105-106
9.
Hsu J, Regillo CD. Distant Trauma with Posterior Segment Effects. Yanoff and Duker: Ophthalmolgoy 3rd ed.
Ch 6.43: 751-752.