|Year : 2021 | Volume
| Issue : 4 | Page : 709-711
Resolution of Purtscher's retinopathy validated with imaging over a period of three months
Dhaivat Shah, Lubhavni Dewan, Shams Tabrez, Manan Solanki, Milind Rokade
Department of Ophthalmology, Choithram Netralaya, Indore, Madhya Pradesh, India
|Date of Submission||12-Mar-2021|
|Date of Acceptance||04-May-2021|
|Date of Web Publication||09-Oct-2021|
Dr. Dhaivat Shah
Choithram Netralaya, Dhar Road, Indore - 453 001, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Purtscher's retinopathy is a well-known finding post trauma. It is microangiopathy occurring due to occlusion of peripapillary terminal arterioles that supply the superficial capillaries. There are numerous reports in literature describing this entity, but seldom any report describing its course and nature of resolution supported with imaging. We present a case of a 21-year-old young male who developed Purtscher's retinopathy post head trauma, with sequential follow-up imaging over a period of 3 months, till near complete resolution of the condition. The supportive imaging also aids in understanding the pathology in a simplified way.
Keywords: OCT, Purtscher's retinopathy, steroids, trauma
|How to cite this article:|
Shah D, Dewan L, Tabrez S, Solanki M, Rokade M. Resolution of Purtscher's retinopathy validated with imaging over a period of three months. Indian J Ophthalmol Case Rep 2021;1:709-11
|How to cite this URL:|
Shah D, Dewan L, Tabrez S, Solanki M, Rokade M. Resolution of Purtscher's retinopathy validated with imaging over a period of three months. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 18];1:709-11. Available from: https://www.ijoreports.in/text.asp?2021/1/4/709/327697
Purtscher's retinopathy, also known as traumatic retinal angiopathy, retinal teletraumatism, or lymphorrhagia retinae, is a well-known clinical entity described by Otmer Purtscher, comprising severe visual decline after head trauma. It is characterized by pathognomonic polygonal retinal white areas around the optic nerve head and fovea (Purtscher flecken) with perivascular clearing, associated with intraretinal hemorrhages and cotton wool spots. Believed to be a microangiopathy occurring due to occlusion of terminal arterioles supplying the superficial peripapillary capillaries numerous case reports exist in literature describing Purtscher's retinopathy. However, to the best of our knowledge, there are seldom reports describing serial follow-up imaging of a patient with Purtscher's retinopathy describing the natural course of resolution. We present here a case with sequential follow-up imaging over a period of 3 months, which helps in understanding the pathology in a simplified manner.
| Case Report|| |
A 21-year-old male presented to our center complaining of diminished vision in the left eye for 2 weeks. He had a history of a road traffic accident and had sustained injury to the right side of the forehead prior to the onset of the visual loss, inciting a right frontoparietal subdural effusion as seen on his MRI. The patient was on anti-coagulants, anti-epileptics, multivitamins, and oral steroids at the time of presentation. The best corrected visual acuity in the right eye was 20/20 and CFCF in the left eye with accurate projection of rays in all quadrants. The intraocular pressure obtained using applanation tonometry was 18 mmHg bilaterally with normal anterior segment examination and normal pupillary reactions. Fundus examination in the right eye was normal, while the left eye revealed multiple confluent peripapillary white patches appearing like cotton wool spots all around the disc, few superficial hemorrhages, and large white well-defined patches in between the vascular arcades at the macula. The temporal involvement appeared to extend up to the fovea clinically, explaining the marked visual loss. Suspecting Purtscher's retinopathy we ordered a fundus picture (Carl Zeiss, Germany) and an OCT (Cirrus HD OCT, Carl Zeiss, Germany) for documentation [Figure 1]a and [Figure 1]b and assessing the foveal involvement, which corroborated with our clinical findings. The patient was counseled regarding the guarded visual prognosis and continued on oral prednisolone (40 mg/day as per the body weight) in a weekly tapering dose.
|Figure 1: At presentation. (a) Peripapillary and macular Purtscher flecken, cotton wool spots, and flame-shaped intraretinal hemorrhages seen around the disc extending to the fovea temporally. (b) Horizontal raster line OCT scan through macula demonstrating retinal edema involving OPL, INL, IPL, GCL, and RNFL with loss of demarcation of inner retinal layers and a maintained foveal contour|
Click here to view
On one week follow-up, the visual acuity in OS had improved to 20/1200. The peripapillary lesions had shrunken in size and number of hemorrhages decreased as evident in the fundus photograph. OCT showed decrease in the inner retinal hyper-reflectivity indicating decreased ischemia [Figure 2]a and [Figure 2]b.
|Figure 2: 1 week follow-up. (a) Resolution of peripapillary cotton wool spots and hemorrhages. Purtscher flecken markedly shrunken and less well defined. (b) Residual hyperreflectivity of inner retinal layers nasal to fovea with loss of demarcation and thinning of inner retina. Foveal contour is well preserved. No change in outer retinal layers|
Click here to view
At the 1-month follow-up, BCVA had improved to 20/400. Peripapillary cotton wool spots and hemorrhages had cleared up and only slight retinal whitening persisted in the original areas of Purtscher flecken. OCT showed marked reduction in inner retinal layer edema with a well-defined foveal contour.
At 2 months, BCVA had improved to 20/40, the lesions had further improved in appearance, and OCT showed thinning and hyper-reflectivity of the inner retinal layers with a well preserved foveal contour.
At 3 months, BCVA improved to 20/30. The fundus showed a near total resolution of the retinopathy, which was supported by the OCT [Figure 3]a and [Figure 3]b.
|Figure 3: 3 months follow-up. (a) Fundus picture showing almost complete resolution of Purtscher's retinopathy. (b) SD OCT image: Thinning and hyperreflectivity of inner retinal layers nasal to a preserved foveal contour. Outer retinal bands including ellipsoid zone are well preserved|
Click here to view
| Discussion|| |
Purtscher's retinopathy typically presents after severe head trauma, chest compression, or long bone fractures. Diagnosis of these conditions as in this case is primarily clinical based on the presence of following criteria: cotton wool spots at the posterior pole (93%), retinal hemorrhages (65%), Purtscher flecken (63%), a probable or plausible explanatory etiology, and a complementary investigation such as OCT or OCTA compatible with the diagnosis. Microembolization of platelet-fibrin thrombi, air, or aggregated leukocytes activated by complement factor C5 is believed to be the causative obstruction of precapillary terminal arterioles supplying the superficial retinal layers resulting in inner layer ischemia and eventual nerve fiber loss and thinning, all which could be serially documented in our case using SD-OCT imaging. Final visual outcome as stated in literature is variable with 50% eyes regaining 2 or more lines of Snellen's visual acuity by 6 months. In our case, the final BCVA documented at 3 months was 20/30 which might be attributable to the sparing of the fovea as well as early initiation of steroids that might have hastened up resolution of edema.
Role of corticosteroids in treatment of Purtscher's retinopathy has been controversial with most series reporting no significant difference between final outcomes with and without steroid administration, although non-statistically significant differences in BCVA at the earlier follow-ups (within first 3 months) indicate that steroids might hasten visual recovery. In our case, the patient was already on oral steroids started by the neurologist and we continued these in a weekly tapering dose. We observed good visual recovery at 3 months despite poor initial visual acuity and extensive retinal lesions extending close to fovea at presentation.
| Conclusion|| |
Purtscher's retinopathy is a clinical diagnosis that needs to be recognized timely and monitored closely. Documentation of the disease using multimodal imaging is useful for patient counseling regarding final visual recovery as well as for the clinician to assess the course of resolution of the disease. Although the disease has a self-limited course, early steroid initiation may hasten visual recovery and prevent significant morbidity, especially when the presenting vision is significantly low, as seen in this case.
We would like to appreciate Dr. Yashas Goyal for helping with the editing of the manuscript and images. We would also like to acknowledge our optometrists Miss. Deepika Nagle, Miss. Srishti Sharma, and Miss. Anjum Khan for their help.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Agrawal A, McKibbin M. Purtscher's retinopathy: Epidemiology, clinical features and outcome. Br J Ophthalmol 2007;91:1456-9.
Buckley SA, James B. Purtscher's retinopathy. Postgrad Med J 1996;72:409-12.
Miguel AIM, Henriques F, Azevedo LFR, Loureiro AJR, Maberley DAL. Systematic review of Purtscher's and Purtscher-like retinopathies. Eye Lond Engl 2013;27:1-13.
Xia D, Chen X, Zhou Q, Xiao S, Yu Y, Wang Y, et al
. Efficacy of Purtscher's retinopathy treatments: A systematic review. Curr Eye Res 2017;42:908-17.
[Figure 1], [Figure 2], [Figure 3]