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Thread: Purtscher's Retinopathy:22 y.o. man with vision loss after trauma.

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    Default Purtscher's Retinopathy:22 y.o. man with vision loss after trauma.

    Purtscher's Retinopathy: 22 y.o. man with vision loss after trauma.


    CC:
    22 year-old male presented to the clinic 2 days after a single vehicle motor vehicle accident who complained of decreased vision in the right eye (OD).
    HPI:
    Patient fell asleep while driving his truck and had no recollection of the crash. He was not wearing a seat belt. His truck had apparently rolled several times. His airbag reportedly had deployed. He was taken to the local emergency treatment center (ETC). There he was noted to have several back contusions, a laceration on the left elbow, and a bruise on his forehead. Computerized tomography (CT) of the head was negative for fracture or intra-cranial bleed. Approximately 1 hour after leaving the ETC, he noticed vision loss OD.
    Past Eye History:
    No previous ocular disease history. No eye surgery, no previous eye nor head trauma.
    Past Medical History:
    No other health issues. Symptoms as noted in HPI--review of systems was otherwise negative.
    Medications: None

    Family History: Noncontributory

    Social History: Noncontributory

    EXAM OCULAR:

    •Visual Acuity: OD-- between hand motions (HM) only and counting fingers at 1 foot; OS--20/20-1
    •Extraocular motility: Full
    •Pupils: 2.4 log unit relative afferent pupillary defect (RAPD), OD
    •Intra-ocular pressure: 14 mmHg, OD and OS
    •External and anterior segment examination: Normal
    •Confrontation visual fields (CVF): OS--Full; OD--nasal hemifield defect
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    Reference:


    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).1¬5 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.

    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.1¬4 These 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.

    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.

    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.

    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.

    .
    Last edited by trimurtulu; 01-06-2009 at 08:25 PM.

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