Handbook of Ocular Disease Management

PURTSCHER'S RETINOPATHY

Signs and Symptoms

Purtscher's retinopathy.

In 1910, Purtscher described the occurrence of bilateral patches of retinal whitening with hemorrhage around the optic disk in patients who had suffered head trauma (angiopathia retinae traumatica).¹⁵ Subsequently, this fundus appearance was observed to be associated with other types of trauma such as crush injuries and chest trauma from automobile accidents, along with a variety of nontraumatic systemic diseases such as acute pancreatitis, systemic lupus erythematosus, thrombotic thrombocytopenic purpura, chronic renal failure and pregnancy.¹⁵

Subjectively, patients experience acute, painless loss of central vision in one or both eyes. Ophthalmo-scopy reveals multiple, variably sized cotton-wool spots (Purtscher-flecken) and intraretinal hemorrhages around the optic nerve head. Unilateral presentations are unusual.¹ Acutely, the optic nerve head and peripheral retina appear normal. Commonly, involved discs will exhibit some degree of pallor over time.

Pathophysiology

Purtscher's retinopathy results from the occlusion of small arterioles by intravascular microparticles generated by the underlying condition.¹⁴These microparticles may consist of fibrin clots, platelet-leukocyte aggregates, fat emboli, air emboli or other particles of similar size that block the arterioles in the peripapillary retina.¹⁴

Histopathologically, evidence exists for retinal capillary obliteration and inner retinal atrophy within the clinically observed areas of retinal whitening. These findings are relatively nonspecific, being pathophysiologically consistent with cotton-wool spots that are commonly associated with a variety of other causes. As noted, the pathology is confined mainly to the retina posterior to the equator. Optic atrophy typically is present in various degrees.¹

Management

No known treatment exists for Purtscher's retinopathy. The retinal whitening (cotton-wool patches) and retinal hemorrhages typically disappear over weeks or months. Unfortunately, however, the prognosis for visual recovery is poor. Speculation is that the visual acuity remains decreased secondary to infarction of either the foveal photoreceptors or optic nerve itself.¹ There are reports in the literature of cases successfully treated with large doses of IV corticosteroids; however, this has not yet become the standard of care.⁶

Clinical Pearls

Neuroimaging of the face, orbit and brain should be completed during any hospital stay to rule out fractures and intracranial lesions following trauma.
Crush injuries, often involving broken bones, are associated with Purtscher's retinopathy.

Regillo C.D. Distant Trauma with Posterior Segment Effects. In: Yanoff M, Duker JS Ophthalmology. Philadelphia, PA: Mosby 1999; 8(44):1 6.
Rhee DJ, Pyfer MF Systemic Disorders; Pregnancy. In: Rhee DJ, Pyfer MF. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins 1999: 460-3.
Gibson SM, Cox A, Ross DJ Purtscher's retinopathy. Injury 2000; 31(6):472-4.
Shah GK, Penne R, Grand MG. Purtscher's retinopathy secondary to airbag injury. Retina 2001; 21(1):68 9.
Roncone DP. Purtscher's retinopathy. Optometry 2002; 73(3):166-72.
Wang AG, Yen MY, Liu, JH. Pathogenesis and neuroprotective treatment in Purtscher's retinopathy. Jpn J Ophthalmol 1998; 42(4):318-22.

Other reports in this section