Purtscher described sudden blindness in patients with severe head trauma due to a remote retinopathy, characterised by bilateral retinal haemorrhages, cotton wool spots, and optic disc swelling seen on fundoscopy. A similar retinopathy has been reported in compressive chest trauma, long bone fractures, and acute pancreatitis. It is less well recognised that Purstcher’s retinopathy can occur unilaterally and following less severe trauma. We present a case of unilateral remote traumatic retinal angiopathy following a fracture dislocation of the shoulder joint.
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Purtscher described sudden blindness in patients with severe head trauma due to a remote retinopathy, characterised by bilateral retinal haemorrhages, cotton wool spots, and optic disc swelling seen on fundoscopy.1 A similar retinopathy has been reported in compressive chest trauma, long bone fractures, and acute pancreatitis.2 The onset of symptoms is typically within 2 days, with patients complaining of decreased vision, often from 6/60 to only being able to count fingers. The retinal lesions gradually settle down over weeks and then the retina may appear normal. In severe cases, pigmentary changes and optic atrophy may ensue. Arteriolar occlusion due to embolisation is considered as the main mechanism involved in the pathogenesis of this condition. Air, fat, granulocyte, or other blood product aggregates formed after complement activation have all been suggested as the emboli responsible for arteriolar occlusion.3–5 It is less well recognised that Purstcher’s retinopathy can occur unilaterally3 and following less severe trauma.6 We present a case of unilateral remote traumatic retinal angiopathy following a fracture dislocation of the shoulder joint.
A 50 year old man presented to the eye clinic with blurred vision in his right eye 2 days after a 50 mph motorcycle accident. He had sustained a dislocation of his right shoulder joint, along with an avulsion fracture of the greater tuberosity of the humerus. The dislocation had been relocated on the same day. He had not suffered ocular or periorbital trauma. On examination, he had a vision of 6/12 in the right eye and 6/6 in the left. Fundoscopy showed scattered cotton wool spots in the right eye, with a few retinal haemorrhages in the macular area (fig 1). The left eye was normal. Visual field testing revealed a right sided central scotoma (fig 2). Fundus fluorescein angiography demonstrated decreased capillary perfusion of the right macular area and no treatment could be offered. Two months later his vision had improved to 6/9, the cotton wool spots and haemorrhages had resolved, but the central scotoma was still present.
Patients who have had traumatic injuries and develop visual symptoms need an ophthalmological referral for dilated retinal examination in order to identify signs of Purstcher’s retinopathy. Although treatment may not be successful, these findings may have medicolegal implications. The patient needs to be counselled as to a guarded visual prognosis.
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