Purtscher retinopathy as the initial sign of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome

Purtscher-like retinopathy: A rare presentation of hematopoietic stem cell transplant-associated thrombotic microangiopathy

Hematopoietic stem cell transplant (HSCT)-associated (TA) thrombotic microangiopathy (TMA) is an acquired disorder and a potentially life-threatening complication after allogeneic HSCT. TA-TMA causes endothelial damage and results in micro-thrombi in capillaries and arterioles. Early detection and treatment of complications associated with TA-TMA might improve outcomes. Purtscher-like retinopathy (PLR) is associated with micro-thrombi that occlude the retinal arteries and cause retinal injury. PLR has been associated with multiple entities, including HUS and TTP, but has not previously been described in the setting of TA-TMA. Here, we describe an 18-year-old male who underwent a mismatched unrelated donor HSCT for relapsed acute lymphoblastic leukemia. The patient was diagnosed with TA-TMA based on standard defined criteria. He presented with acute onset of blurred vision with findings of multiple white retinal patches, retinal hemorrhages, and macular edema, thought initially to be hypertensive retinopathy. However, on further evaluation using fluorescein angiography and optical coherence tomography, the diagnosis was determined to be PLR. The patient was treated with intravitreal steroid injections (triamcinolone acetonide) with dramatic improvement of vision. The aim of this report is to make clinicians aware of PLR as a potential ocular complication associated with TA-TMA and that prompt intervention might reverse visual impairment.

Acute kidney injury in a patient with hemolytic anemia and thrombocytopenia

Atypical hemolytic uremic syndrome (HUS) is clinically difficult to distinguish from HUS and thrombotic thrombocytopenic purpura. Atypical HUS results from dysregulation of complement activation causing thrombotic microangiopathy affecting multiple organ systems. Atypical HUS is associated with high morbidity and mortality, making early recognition and appropriate therapy necessary to improve patient outcomes.

Purtscher-like retinopathy - A rare complication of acute myocardial infarction and a review of the literature

Purtscher-like retinopathy is an uncommon condition with features similar to Purtscher retinopathy but have non-traumatic causes. Several pathogenic mechanisms have been put forth with differing views on treatment options. We describe for the first time, a case of Purtscher-like retinopathy which developed following a myocardial infarct and a transient ischemic attack. We present a review of the literature on this condition, describing the various clinical presentations, investigation findings, treatment options and prognosis.

Reversal of threatening blindness after initiation of eculizumab in Purtscher-like retinopathy secondary to atypical hemolytic uremic syndrome

Purtscher-like retinopathy, a rare manifestation of systemic thrombotic microangiopathy, is a potentially visually debilitating condition with no effective proven treatment. Distinct pathogenic pathways have been proposed as etiological factors. We revisit the etiology of Purtscher-like retinopathy based on the rapid response and profound visual improvement after initiation of systemic intravenous eculizumab, an inhibitor of the complement cascade, in a patient with Purtscher-like retinopathy secondary to familial atypical hemolytic uremic syndrome (aHUS) due to a mutation in complement factor H. We hypothesize that the efficacy of eculizumab in this patient provides evidence for pathogenic events in the retina similar to those encountered in the renal microvasculature of aHUS patients, namely complement-mediated thromboembolization as a result of activation of the complement cascade in endothelial cells with release of tissue factor and development and amplification of a procoagulant state. To the best of our knowledge, this is the first report in the literature of eculizumab as an effective therapeutic strategy in Purtscher-like retinopathy.

[Vitrectomy for retinal proliferation in childhood following hemolytic uremic syndrome]

The formation of retinal membranes can occur due to a variety of reasons but they are most commonly idiopathic due to the aging process. In addition, epiretinal and subretinal membranes can be formed after severe infections. The present case description shows the appearance of a retinal membrane after hemolytic uremic syndrome caused by Shiga toxin positive E. coli. The question arose whether the patient would benefit from vitrectomy with membrane peeling because of the presence of both epiretinal and subretinal gliotic changes. After the operation on the more severely affected right eye a morphological improvement could be achieved so that an operation on the left eye was also recommended. Judging by the course of this case vitrectomy with membrane peeling seems to be a useful instrument even for the simultaneous presence of subretinal and epiretinal membranes.

Bilateral tractional retinal detachment in a patient with hemolytic-uremic syndrome

Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy characterized by hemolytic anemia, acute kidney injury, and thrombocytopenia. Ophthalmic manifestations of HUS range from mild, including scattered intraretinal hemorrhages, to severe, including a Purtscher-like retinopathy and iris and optic disk neovascularization (NVD). We report the case of a 23-month-old girl with severe HUS who presented with bilateral dense vitreous hemorrhage. During vitrectomy, optic disk neovascularization and funnel-shaped, tractional detachments of both retinas were observed. To our knowledge, this is the first reported case of tractional retinal detachment in the context of HUS.

Recurrent ocular involvement in pediatric atypical hemolytic uremic syndrome

Atypical hemolytic uremic syndrome (HUS) is a subtype of thrombotic microangiopathy associated with complement alternative pathway dysregulation. It is clinically characterized by a relapsing course and a poor prognosis. Multiple organ systems are commonly affected by thrombotic microangiopathy in pediatric atypical HUS; however, ocular involvement is rarely reported. The case of an 11-year-old girl diagnosed as having atypical HUS who presented with bilateral central retinal vein occlusions with macular subhyaloid hemorrhage during her initial onset and ophthalmoplegia, diplopia, and optic disc edema during her relapsing episode 1 year later is described. All ocular manifestations occurred in the convalescence phase of atypical HUS. No other extrarenal complications were found and full recovery was achieved following typical treatment for atypical HUS (ie, plasma infusion, steroid, and supportive therapy). This is thought to be the first reported case of recurrent ocular involvement in pediatric atypical HUS.

Purtscher's retinopathy associated with acute pancreatitis

PURPOSE

Purtscher's retinopathy is a rare condition that is associated with complement-activating systemic diseases such as acute pancreatitis. After pancreatic injury or inflammation, proteases such as trypsin activate the complement system and can potentially cause coagulation and leukoembolization of retinal precapillary arterioles. Specifically, intermediate-sized emboli are sufficiently small enough to pass through larger arteries yet large enough to remain lodged in precapillary arterioles and cause the clinical appearance of Purtscher's retinopathy. This pathology may present with optic nerve edema, impaired visual acuity, visual field loss, as well as retinal findings such as cotton-wool spots, retinal hemorrhage, artery attenuation, venous dilation, and Purtscher flecken.

CASE REPORT

A 57-year-old white man presented with an acute onset of visual field scotomas and decreased visual acuity 1 week after being hospitalized for acute pancreatitis. The retinal examination revealed multiple regions of discrete retinal whitening surrounding the disk, extending through the macula bilaterally, as well as bilateral optic nerve hemorrhages. The patient identified paracentral bilateral visual field defects on Amsler Grid testing, which was confirmed with subsequent Humphrey visual field analysis. Although the patient presented with an atypical underlying etiology, he exhibited classic retinal findings for Purtscher's retinopathy. After 2 months, best corrected visual acuity improved and the retinal whitening was nearly resolved; however, bilateral paracentral visual field defects remained.

CONCLUSIONS

Purtscher's retinopathy has a distinctive clinical presentation and is typically associated with thoracic trauma but may be a sequela of nontraumatic systemic disease such as acute pancreatitis. Patients diagnosed with acute pancreatitis should have an eye examination to rule out Purtscher's retinopathy. Although visual improvement is possible, patients should be educated that there may be permanent ocular sequelae.

Systematic review of Purtscher's and Purtscher-like retinopathies

PURPOSE

(1) To describe the clinical characteristics of Purtscher and Purtscher-like retinopathies, including etiologies, fundoscopic signs, results of complementary investigation, treatments, and outcomes. (2) To compare visual acuity (VA) of patients receiving corticosteroids for PuR compared with observation.

METHODS

Systematic review of several databases (1980-2010): Medline, EMBASE, ISI, EBSCO, Science Direct and Google Scholar. Study selection criteria included: (A) Studies of PuR with ophthalmology assessments; (B) ≥3 of 5 diagnostic criteria of PuR; (C) Quantified VA at presentation. For quantitative assessment (purpose 2), we selected only studies that reported whether corticosteroids were administered, and with vision assessments after at least 1 month.

RESULTS

(1) From 670 studies initially found, 40 were included (68 cases, 110 eyes): 1 prospective, 5 case series, and 34 case reports. Mean VA at presentation was 1.3 logMAR (logarithm of the minimum angle of resolution) (<20/200; range: 20/20-light perception). Purtscher flecken were underreported. Trauma and acute pancreatitis were the most frequent etiologies. There were six deaths, all with systemic associations. (2) There was no statistically significant difference between VA improvement for patients treated with corticosteroids compared with observation. Visual prognostic factors identified included etiology (pancreatitis and trauma were associated with higher probability of visual improvement) and male gender.

CONCLUSION

Due to limitations of case reports and series, the presented data are only useful as broad characterizations of the clinical course of PuR. Further studies, possibly including trials to assess the effectiveness of corticosteroids use, and larger prospective cohort studies, are necessary, but may not be feasible to conduct.

Thrombotic microangiopathy and Purtscher-like retinopathy as a rare presentation of juvenile dermatomyositis

Juvenile dermatomyositis is a rare systemic vasculopathy that may sometimes present with acute complications. We report here the case of a 7-year-old boy with severe dermatomyositis associated with thrombocytopenia and blurry vision. The presence of schistocytosis and the secondary occurrence of hemolytic anemia were consistent with a diagnosis of thrombotic thrombocytopenic purpura (TTP). Further investigations demonstrated the association of TTP with muscular microangiopathy and Purtscher-like retinopathy. Retinal and hematologic involvements dramatically improved after the initiation of plasma exchange in emergency. This report emphasizes that early recognition of TTP and prompt plasmapheresis are important in a child with severe juvenile dermatomyositis associated with thrombocytopenia.

Ocular involvement in paediatric haemolytic uraemic syndrome

PURPOSE

The aim of this study was to estimate the frequency and severity of ocular involvement in paediatric patients with haemolytic uraemic syndrome (HUS).

METHODS

The study was designed as an institutional, retrospective, observational case series. Charts for all 87 paediatric patients with HUS treated at the University Children's Hospital Zurich between 1995 and 2007 were reviewed. Patients with ocular involvement were identified and clinical findings presented.

RESULTS

Three of 69 examined patients with HUS showed ocular involvement. Ophthalmic findings in two children were consistent with bilateral Purtscher retinopathy, showing multiple haemorrhages, exudations and superficial retinal whitening. The third child presented with bilateral isolated central intraretinal haemorrhages as a milder form of ocular involvement. In one of the children with Purtscher retinopathy, laser photocoagulation was required for bilateral rubeosis irides and development of disc neovascularization. Longterm outcomes in the two severely affected children showed decreased visual acuity caused by partial atrophy of the optic nerves. In the milder case visual acuity was not impaired at any time.

CONCLUSIONS

A minority of paediatric patients with HUS developed ocular involvement. Acute ocular findings varied in severity from isolated intraretinal haemorrhages to Purtscher-like retinopathy with retinal ischaemia. Longterm complications included the development of neovascularizations and consecutive optic nerve atrophy. Although ocular involvement in HUS seems to be rare, physicians should be aware of this complication because of its possible vision-endangering consequences.

Atypical presentations of thrombotic thrombocytopenic purpura: a review

Thrombotic thrombocytopenic purpura (TTP) is diagnosed by the presence of microangiopathic hemolytic anemia and thrombocytopenia in a patient who frequently presents with central nervous system involvement and, to a lesser extent, renal dysfunction. Recent understanding of the pathophysiology of TTP due to severe deficiency of von Willebrand factor cleaving protease, known as ADAMTS13, has improved diagnosis of TTP. Once the diagnosis is suspected, life-saving therapeutic plasma exchange therapy is initiated. Occasionally, an unusual clinical presentation makes TTP diagnosis difficult, thus resulting in a delay in the management of TTP. This review highlights a variety of atypical TTP presentations described in the literature. It is intended to bring unusual scenarios to the clinician's awareness, so that timely treatment can be delivered.

[Purtscher-like retinopathy: case report and review of the literature]

Purtscher's retinopathy is a rare condition, seen in patients with a history of trauma. Purtscher-like retinopathy includes the nontraumatic causes of this retinal disease, which is often misdiagnosed. The diagnosis is based on clinical settings and is supported by intravenous fluorescein angiography. We describe a case of acute, severe retinopathy in a patient experiencing a scleroderma renal crisis. We discuss the pathogeny, prognosis and treatment, which is still widely controversial.

Purtscher-like retinopathy as an initial presentation of a thrombotic microangiopathy associated with antineoplastic therapy

We describe the case of a 31-year-old female with Hodgkin's lymphoma who developed renal and retinal thrombotic microangiopathy (TM) months after autologous bone marrow transplantation. Presenting symptoms were ocular and examination findings were consistent with a Purtscher-like retinopathy. This case demonstrates that patients being treated with antineoplastic therapy who develop TM should have an ocular examination for Purtscher retinopathy. The visual prognosis of Purtscher retinopathy is guarded.

[Correlation of retinal thickness with the extent of Purtscher's retinopathy]

BACKGROUND

The course of Purtscher's retinopathy (PR) or Purtscher-like retinopathy (P-lR) is dependent on time, length, and expression of confluent cotton-wool spots. To correlate the course of the disease with findings of optical coherence tomography (OCT), we present two extreme courses of PR and P-lR.

METHODS

Complete ophthalmological examination plus electroretinography (ERG) and OCT were performed. In the first case the follow-up was carried out until complete resorption of the edema and in the second case 8 years after the occurrence of P-lR.

RESULTS

An increase of the central retinal thickness (308-430 microm was observed during the acute phase of PR. Normalization of visual acuity and central retinal thickness to 210-273 microm with an ERG within normal limits (35 ms) was achieved after 8 weeks. In the course of P-lR the marked edema was visible even after 6 months and a markedly reduced neuroretina (112-120 microm) was measured after 8 years.

CONCLUSIONS

Retinal thickness analysis correlates well with organic functions in the cases of PR or P-lR. Fast reduction of the edema was associated with a good prognosis for visual acuity.

Purtscher's and Purtscher-like Retinopathies: A Review

Purtscher's retinopathy is a rare condition, seen in patients with a history of trauma or other systemic disease. The clinical appearance would suggest embolic occlusion of the pre-capillary arterioles as the most likely pathogenesis, although other factors leading to blood-vessel damage may also contribute. The diagnosis is made on clinical grounds and supported by intravenous fluorescein angiography. Without treatment, the majority of patients recover some of their visual function. Treatment with systemic steroids may improve visual outcome in some patients but at present there is little evidence to support such treatment routinely.

[Prognosis and differential diagnosis of Purtscher's retinopathy]

BACKGROUND

Purtscher's retinopathy is accompanied by a distinct loss of vision as a result of severe trauma to the chest or skull. Reports on visual prognosis in the literature are not uniform.

PATIENTS

The data of 10 patients with Purtscher's retinopathy from the department of Ophthalmology in Freiburg, published data from 55 patients with Purtscher's retinopathy and 20 patients with traumatic retinal hemorrhages taken from the literature were evaluated.

RESULTS

The average visual acuity of the 10 patients from Freiburg was 0.3 within a short period after the accident and the final average visual acuity was 0.46. The average visual acuity of the 55 patients with Purtscher's retinopathy was 0.21 within a short period after the accident with an average final visual acuity of 0.61. The average visual acuity of the 20 patients with traumatic retinal hemorrhages from the literature was 0.45 within a short period after the accident with an average final visual acuity of 0.74. Therefore the initial and the final visual acuity were better in patients with traumatic retinal hemorrhages compared to patients with Purtscher's retinopathy.

CONCLUSION

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.