OcuLearning › Retina

Purtscher Retinopathy

URGENT — Retina

Symptoms

  • sudden, severe decrease in vision (often bilateral)
  • history of severe compression injury (chest, head, or lower extremities)
  • sudden vision loss 24–48 hours after a major systemic event (pancreatitis, fracture)

Clinical Findings

Classic fundus appearance

  • Purtscher flecken: pathognomonic polygonal patches of superficial retinal whitening
  • perivascular clearing: a "halo" of normal retina immediately surrounding the vessels within whitened areas
  • cotton-wool spots (cws): clustered around the optic nerve and macula
  • intraretinal hemorrhages: scattered in the posterior pole

Additional signs

  • macular pseudo–cherry-red spot (due to surrounding retinal edema)
  • optic disc edema (late) or relative afferent pupillary defect (rapd)
  • serous macular detachment or dilated, tortuous vessels

Etiology

Pathophysiology

  • microembolic occlusion of peripapillary retinal arterioles
  • mechanical or complement-mediated (c5a) leukoembolization

Classic causes (true Purtscher)

  • trauma: severe blunt chest compression (crush), head trauma, or long-bone fractures (fat embolism)

Non-traumatic (Purtscher-like)

  • acute pancreatitis (most common non-traumatic cause)
  • systemic lupus erythematosus (sle) or other vasculitides
  • obstetric: childbirth, eclampsia, or amniotic fluid embolism
  • hematologic: ttp, hellp syndrome, or chronic renal failure

Red Flags

  • sudden bilateral vision loss after trauma or childbirth
  • multiple posterior pole cotton-wool spots without a history of diabetes or htn
  • high lipase/amylase: presence of retinopathy in a patient with abdominal pain is diagnostic for pancreatitis-associated Purtscher

Investigations

Ocular exam

  • dilated fundus exam: look for the "flecken" and perivascular sparing
  • oct macula: shows inner retinal hyper-reflectivity (edema/ischemia) in acute phase
  • fa (fluorescein angiography): demonstrates arteriolar non-perfusion and leakage

Systemic workup

  • labs: lipase, amylase, cbc, coagulation profile, ana, and complement levels
  • imaging: chest ct or mri as indicated by the trauma history

Treatment

Systemic management

  • focus entirely on treating the underlying cause (e.g., stabilize fractures, manage pancreatitis)

Ocular management

  • observation: spontaneous recovery of some vision occurs in ~50% of patients
  • steroids: iv methylprednisolone is sometimes used in severe cases but lacks strong evidence
  • supportive care: referral for low-vision rehabilitation if permanent scotomas persist

Clinical Pearl

Purtscher flecken surrounding the disc and macula after trauma, pancreatitis, or childbirth point to complement-mediated arteriolar occlusion — treat the systemic cause and watch the retina recover.

Differential Diagnosis

  • • central retinal vein occlusion (crvo) — more widespread hemorrhages, "blood and thunder"
  • • central retinal artery occlusion (crao) — diffuse whitening, no flecken/sparing
  • • ttp or sle vasculitis
  • • radiation retinopathy

Related Retina Conditions