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Purtscher’s Retinopathy
Delhi J Ophthalmol 2014; 25 (2): 125-128
DOI: http://dx.doi.org/10.7869/djo.92
Anil Kumar Verma, Rajeev Tuli,
Gaurav Sharma,
Deepak Sharma
Department of Ophthalmology
Dr RPG Medical College,
Tanda, Himachal Pradesh, India
*Address for correspondence
Anil Kumar Verma MS
Department of Ophthalmology
Dr R P G Medical College, Tanda,
Himachal Pradesh, India
Email: [email protected]
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)
Introduction
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).
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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
Del J Ophthalmol 2014;25(2)
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Purtscher’s Retinopathy
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Figure 1 (Case I): Clinical photograph of OD on day of presentation
Figure 2 (Case I): Clinical photograph of OD on after five month followup
Figure 3 (Case I): Clinical photograph of OS on day of presentation
Figure 4 (Case I): Clinical photograph of OS after five month followup
Figure 5 (Case 2): Clinical photograph of OS on day of presentation
Figure 6 (Case 2): Clinical photograph of OD after five month followup
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Verma A K et al
Figure 7 (Case 2): Clinical photograph of OS on day of presentation
Figure 8 (Case 2): Clinical photograph of OS after five month followup
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).
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
atrophy1. 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 al9 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
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
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Del J Ophthalmol 2014;25(2)
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Purtscher’s Retinopathy
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
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References
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