Sudden visual impairment is a key characteristic of Purtscher's retinopathy. All reported cases involve individuals who experienced symptoms, like reduced visual acuity and visual field or a combination of both with the majority of the patients reporting combined defects of visual acuity and visual field [1]. Extremely profound ocular dysfunction, such as sudden blindness, may also be induced, as can annular, central or paracentral scotomas and extensive defects occupying various segments of the visual field [2].

Ocular symptoms usually arise 1-2 days after a traumatic event or other acute, Purtscher's-retinopathy-related conditions [3] [4] [5]. The aforementioned defects associated with vision loss can be unilateral or bilateral.

Other features of Purtscher's retinopathy are due to the fact that it is strongly associated with extraocular trauma. So patients may present with evidence of head or thoracic injuries. Individuals who have developed the retinopathy without prior trauma may present with symptoms of a variety of other pathologies that have been associated with the condition. These include:

• Acute pancreatitis
• Childbirth [6] [7]
• Preeclampsia
• Thrombocytopenic purpura
• Cryoglobulinemia
• Scleroderma
• Systemic lupus erythematosus
• Long bone fractures

• Pallor

  The most common chronic signs were optic disc pallor and atrophy of the retinal pigment epithelium. Without treatment, 50% of eyes improved by at least 2 Snellen lines at final follow-up and 23% improved by at least 4 Snellen lines. [ncbi.nlm.nih.gov]

  But there was optic disc pallor in the right eye along with RAPD (Figure-3). [djo.org.in]

  […] predilection OCULAR SIGNS Retina Cotton-wool spots Peri-papillary retinal whitening with macular involvement Pre-retinal and/or retinal hemorrhages Macular edema Dilated retinal venous system Optic Nerve Typically normal, but may have: Disc edema Disc pallor [webeye.ophth.uiowa.edu]

• Surgical Procedure

  View videos of surgical procedures and access the complete contents of Retina, 5th Edition online at www.expertconsult.com, fully searchable, with regular updates and a downloadable image gallery. [books.google.com]

  Retinal Perforations, Breaks Surgical Procedures and Postoperative Cases Toxic Retinopathies; see also Light Toxicitiy Trauma (Injury) Battered Child Syndrome Berlin's Edema, Retinopathia Sclopetaria Foreign Body Injury Homonymous Hemispheric Degeneration [atlasophthalmology.net]

• Malaise

  It s a systemic disorder and patients may also have general malaise, headaches, thickened, tender temporal arteries, pulsating temporal artery, scalp tenderness, muscle tenderness and jaw claudication (pain or weakness when chewing). [authorstream.com]

• Hypertension

  Poorly controlled pregnancy-induced hypertension coupled with the hypercoagulable state of pregnancy probably led to a compromised optic nerve microvasculature and loss of retinal autoregulation. [ncbi.nlm.nih.gov]

  Furthermore, aside from cotton wool spots, our patient demonstrated none of the characteristic findings of these retinopathies, though the possibility of a delayed presentation of a hypertensive crisis without chronic hypertensive changes remains. 4. [hindawi.com]

  Moseman CP, Shelton S Nov (2002) Permanent blindness as a complication of pregnancy-induced hypertension. Obstet Gynecol 100, No.5, Part 1:943–945 Google Scholar 5. [doi.org]

  Anterior Chamber Brain and Optical Pathway Choroid Congenital Syndromes, Malformations and Abnomalities Conjunctiva Cornea Glaucomas, Ocular Hypertension Hypertensive Retinopathy Iris and Ciliary Body Lacrimal System Lens Lids Neuro-Ophthalmology Optic [atlasophthalmology.net]

  His medical history was significant for untreated borderline hypertension and benign prostatic hyperplasia. He had no history of stroke, cardiac disease, hypercholesterolemia, diabetes, or smoking. [journals.sagepub.com]

• Fracture

  We present a case of unilateral remote traumatic retinal angiopathy following a fracture dislocation of the shoulder joint. [ncbi.nlm.nih.gov]

  Purtscher’s retinopathy associated with mandibular fracture: a case report. J Trauma1996;40:141–3. [emj.bmj.com]

  Links Authors +Show Affiliations, Canniesburn Hospital, Bearsden, Glasgow., Source MeSH Blindness Frontal Bone Humans Male Middle Aged Retinal Hemorrhage Skull Fractures Zygomatic Fractures Pub Type(s) Case Reports Journal Article Review Language eng [unboundmedicine.com]

• Contusion

  We present a patient who had Purtscher's retinopathy in both eyes after sustaining a chest contusion. After multiple sessions of hyperbaric oxygen (HBO) therapy were given, visual function and retinal appearance improved. [ncbi.nlm.nih.gov]

  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. [webeye.ophth.uiowa.edu]

  Our case was unique in its unilateral presentation, opposite to the site of impact, without evidence of any internal contusions, bony injuries, or organ damage. It is also unusual that the disease manifested after a period of 48 hours post-trauma. [mamcjms.in]

• Cotton Wool Spots

  The patient was diagnosed with Purtscher's retinopathy in the right eye due to cotton-wool spots observed during fundus examination, an air embolism discovered on chest X-ray, and a history of head/chest trauma. [ncbi.nlm.nih.gov]

  McLeod D: Why cotton wool spots should not be regarded as retinal nerve fibre layer infarcts. Br J Ophthalmol 2005;89:229–237. [karger.com]

  wool spots and/or superficial hemorrhages in over 92% of cases. [slideplayer.com]

• Retinal Hemorrhage

  In spite of severe initial retinal findings, the visual prognosis is usually not disappointing. Prognosis of visual acuity was better in patients with traumatic retinal hemorrhages compared to patients with Purtscher's retinopathy. [ncbi.nlm.nih.gov]

  […] whitening and retinal hemorrhages surrounding the optic nerve. [djo.org.in]

  […] whitening and cotton wool patches that are retinal microinfarctions at nerve fiber layer with or without retinal hemorrhages. [meajo.org]

  Characteristic findings include multiple areas of superficial retinal whitening, soft exudates, and retinal hemorrhages adjacent to the optic disc. [healio.com]

• Hypertensive Retinopathy

  Anterior Chamber Brain and Optical Pathway Choroid Congenital Syndromes, Malformations and Abnomalities Conjunctiva Cornea Glaucomas, Ocular Hypertension Hypertensive Retinopathy Iris and Ciliary Body Lacrimal System Lens Lids Neuro-Ophthalmology Optic [atlasophthalmology.net]

  Monitor for visual recovery Treat other associated trauma or systemic disease (i.e., pancreatitis, and systemic vasculitis) Differential Diagnoses for Purtscher's Retinopathy Commotio Retinae Hypertensive retinopathy Diabetic retinopathy HIV retinopathy [webeye.ophth.uiowa.edu]

  Differential Diagnosis: Circumpapillary Cotton Wool Spots Acute pancreatitis Diabetic retinopathy Hypertensive retinopathy Radiation retinopathy Interferon retinopathy HIV retinopathy Long bone fracture/orthopedic surgery Chest compression injuries Chronic [westcoastretina.com]

• Visual Impairment

  Sudden visual impairment is a key characteristic of Purtscher's retinopathy. [symptoma.com]

  Abstract This case study describes a patient with multiple trauma associated with acute visual impairment. Funduscopic examination revealed scattered and confluent cotton wool exudates bilaterally. [ncbi.nlm.nih.gov]

  Abstract Purtscher retinopathy is an occlusive microangiopathy associated with traumatic causes and usually causes visual impairment. For non-traumatic origins, it is called Purtscher-like retinopathy (PLR). [pubmed.ncbi.nlm.nih.gov]

  American Journal of Ophthalmology 134(1): 125-128, July, 2002 Purtscher's retinopathy: a case of visual impairment associated with multiple trauma. [eurekamag.com]

  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 ]. [djo.org.in]

• Visual Impairment

  Sudden visual impairment is a key characteristic of Purtscher's retinopathy. [symptoma.com]

  Abstract This case study describes a patient with multiple trauma associated with acute visual impairment. Funduscopic examination revealed scattered and confluent cotton wool exudates bilaterally. [ncbi.nlm.nih.gov]

  Abstract Purtscher retinopathy is an occlusive microangiopathy associated with traumatic causes and usually causes visual impairment. For non-traumatic origins, it is called Purtscher-like retinopathy (PLR). [pubmed.ncbi.nlm.nih.gov]

  American Journal of Ophthalmology 134(1): 125-128, July, 2002 Purtscher's retinopathy: a case of visual impairment associated with multiple trauma. [eurekamag.com]

  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 ]. [djo.org.in]

• Suggestibility

  This case suggests that HBO therapy may be a treatment option for Purtscher's retinopathy. [ncbi.nlm.nih.gov]

Fundoscopy is the first step towards achieving an accurate diagnosis of Purtscher's retinopathy. Findings consistent with this diagnosis include [4]:

• Cotton-wool spots. These constitute restricted regions of retinal ischemia, which are observed as white areas of axonal swelling obstructing the axoplasmal flow and are detected in up to 90% of the cases [8] [9].
• Retinal hemorrhages may appear on the superficial nerve fiber, in which case they display a flame-like shape, or on the inner retinal layers; in the latter case, they assume a "dot and blot" pattern. They are also observed in up to 90% of the affected patients.
• "Purtscher flecken" are deemed pathognomonic for Purtscher's retinopathy but are detected in only half of the patients [9]. Purtscher flecken are polygonal regions of whitening of the retina; it is believed that they occur due to regional capillary bed infarction.
• Normal optic disc, which tends to assume an edematous appearance later in the course of the disorder.

Another diagnostic modality that can be employed is fluorescein angiography. It is expected to illustrate regional ischemia of the retina and capillary bed, possibly accompanied by venous dilation and perivenous staining [10].

Given the fact that Purtscher's retinopathy is primarily associated with extraocular trauma, especially head or thoracic trauma, workup may include a radiograph or a computerized tomography scan (CT scan) of the affected region. In case the retinopathy is not induced by trauma, it may be linked to other diseases, such as acute pancreatitis, activated complement C5a, systemic lupus erythematosus, scleroderma, dermatomyositis and other pathologies. Therefore, laboratory tests that need to be performed to assess these possibilities encompass:

• Serum amylase, transaminase, myoglobin, aldolase, creatine phosphokinase, urine myoglobin
• Serum rheumatoid factor, ANA, anti-double-stranded DNA antibody
• Complement C5a levels

CONCLUSIONS: Both treatment and no treatment improve vision in Purtscher's retinopathy patients, but the difference between no treatment and glucocorticoid therapy had no statistical significance. [ncbi.nlm.nih.gov]

Pathogenesis and neuroprotective treatment in Purtscher's retinopathy. Jpn J Ophthalmol 1998;42:318–322. 9. Atabay C, Kansu T, Nurlu G. Late visual recovery after intravenous methylprednisolone treatment of Purtscher's retinopathy. [synapse.koreamed.org]

The appearance of PLR may be associated with the implantation of an endovascular stent for the treatment of intracranial aneurysms. [pubmed.ncbi.nlm.nih.gov]

Reports on visual prognosis in the literature are not uniform. [ncbi.nlm.nih.gov]

Prognosis Purtscher's retinopathy can lead to loss of vision, [7] and recovery of vision may occur very little. [2] However, vision recovery does occur in some cases, and reports have varied on the long-term prognosis. [8] References ↑ Purtscher O (1912 [wikidoc.org]

The etiology of this phenomenon has been linked to fat necrosis and involvement of complement and the immune system. [ncbi.nlm.nih.gov]

We review the literature on posttraumatic retinopathies; and outline the clinical characteristics of interest for injury assessment, as well as the differential diagnosis with other etiologies(AU) Responsible library: ES1.1 Localization: BNCS [pesquisa.bvsalud.org]

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. [slideplayer.com]

Scientific report Clinical science - Scientific reports Purtscher’s retinopathy: epidemiology, clinical features and outcome Ashish Agrawal 1, Martin McKibbin 2 1 External Eye Diseases & Refractive Surgery, Manchester Royal Eye Hospital, Manchester, UK [doi.org]

Purtscher’s retinopathy: epidemiology, clinical features and outcome. Br J Ophthalmol. 2007;91(11):1456–9. CrossRef PubMed PubMedCentral Google Scholar 2. Behrens-Baumann W, Scheurer G, Schroer H. Pathogenesis of Purtscher’s retinopathy. [link.springer.com]

Purtscher’s retinopathy: epidemiology, clinical features and outcome. Br J Ophthalmol 2007 ; 91 : 1456 –9. [cmaj.ca]

"Purtscher's retinopathy: epidemiology, clinical features, and outcome". British Journal of Ophthalmology. 91 (11): 1456–9. doi : 10.1136/bjo.2007.117408. PMC 2095457. PMID 17556428. ↑ Schmidt, D; Otto, T (June 2004). [wikidoc.org]

The case is presented with a discussion of the pathophysiology, diagnosis, prognosis, and treatment options for this entity. [ncbi.nlm.nih.gov]

Pathophysiology Purtscher's retinopathy likely involves complex pathophysiology, with several contributing factors, including complement -mediated aggregates, fat, air, fibrin clots and platelet clumps. [5] The diseases leads to the formation of cotton [wikidoc.org]

Using intravital fluorescence microscopy, we observed PMN aggregation and embolization in the mesenteric vessels of rats given intra-arterial infusions of ZAP; this was also prevented by pretreatment with 30 mg/kg MP. [jci.org]

Treatment to prevent further occurrences may involve treating heart arrhythmias, hypertension, carotid stenosis, and high cholesterol. [authorstream.com]

"Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. [turkiyeklinikleri.com]

Few studies reported strategies to prevent selection bias, information bias, or other bias. Risk of bias in each study for each of those variables can be requested to the corresponding author. Figure 2 Risk of bias graph. [nature.com]

1. Agrawal A, McKibbin M. Purtscher's retinopathy: epidemiology, clinical features and outcome. Br J Ophthalmol. 2007 Nov; 91(11): 1456–1459.
2. Blodi BA, Johnson MW, Gass JD, Fine SL, Joffe LM. Purtscher's-like retinopathy after childbirth. Ophthalmology. 1990 Dec;97(12):1654-9.
3. Stewart MW, Brazis PW, Guier CP, Thota SH, Wilson SD. Purtscher-like retinopathy in a patient with HELLP syndrome. Am J Ophthalmol. 2007 May; 143(5):886-7.
4. Buckley SA, James B. Purtscher's retinopathy. Postgrad Med J 1996; 72: 409 -412.
5. Purtscher O. Noch unbekannte Befunde nach Schaedeltrauma. Ber Ophthalmol Ges 1910; 36: 294-310.
6. Marr WG, Marr EG. Some observation on Purtscher's disease: traumatic retinal angiopathy. AmJ Ophthalmol 1962; 54: 69Q-7t)5.
7. Roden D, Fitzpatrick G, O' Donoghue H, Phelan D. Purtscher's retinopathy and fat embolism. British Journal of Ophthalmology. 1989; 73: 677-679.
8. Proença Pina J, Ssi-Yan-Kai K, de Monchy I, Charpentier B, Offret H, Labetoulle M. Purtscher-like retinopathy: case report and review of the literature. J Fr Ophtalmol. 2008;31 (6:609).
9. Miguel AIM, Henriques F, Azevedo LFR, Loureiro AJR, Maberley DAL. Systematic review of Purtscher's and Purtscher-like retinopathies. Eye (Lond). 2013 Jan; 27(1): 1–1.
10. Williams DF, Mieler WF, Williams GA. Posterior segment manifestations of ocular trauma. Retina 1990; 1O(suppl 1): 35-44.