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Multimodal Imaging in Purtscher Retinopathy

Xiao, Wei MD; He, Liwen MD; Mao, Yuxiang MD; Yang, Huasheng MD

Section Editor(s): Toth, Cynthia A.; Walter, Scott D.; Finn, Avni P.

doi: 10.1097/IAE.0000000000002218
Photo Essay

State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, PR China

Reprint requests: Huasheng Yang, MD, Zhongshan Ophthalmic Center, Guangzhou 510060, PR China; e-mail:

Supported by the Natural Science Foundation of Guangdong Province, China (Wei Xiao, 2016A030310230).

None of the authors has any financial/conflicting interests to disclose.

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Purtscher retinopathy is a rare condition that occurs in patients with a history of trauma distant from the eyes.1 Typical manifestations, including cotton wool spots, retinal hemorrhages, and optic disk swelling, are confined to the posterior pole, and often appear bilaterally. The pathogenesis underlying Purtscher retinopathy is not clear, but might be related to the embolic occlusion of precapillary retinal arterioles. Diagnosis is usually made on clinical grounds, and supported by fluorescein angiography. For the majority of cases, visual function could recover to various extents without treatment.2

We hereby reported a case of a 65-year-old man who complained of decreased vision 2 days after a motor vehicle accident. No apparent ocular trauma was observed, but contusion of his forehead and fractures of two ribs were noted. Best-corrected visual acuity was 20/200 and 20/800 in his right eye and left eye, respectively. Anterior segments were normal except for mild senile cataracts. Ophthalmoscopy revealed bilateral, nearly symmetric retinopathy with multiple cotton wool spots and flame hemorrhages (Figure 1A); therefore, we only presented images of his left eye. Optical coherence tomography angiography revealed flow voids in both the superficial capillary plexus (Figure 1B) and deep (Figure 1C) capillary plexus, which resulted in a markedly enlarged foveal avascular zone (4.04 mm2). Fluorescein angiography showed multifocal filling defect and irregularly enlarged foveal avascular zone (Figure 1D). Widefield swept-source optical coherence tomography (Figure 1E) detected inner limiting membrane detachment, hyperreflectivity of the inner/middle retinal layers (i.e., paracentral acute middle maculopathy, Figure 1E), and disruption of ellipsoid zone (Figure 1E).

Fig. 1

Fig. 1

With the ability to delineate superficial capillary plexus and deep capillary plexus separately, optical coherence tomography angiography has been applied to evaluate many retinal vascular diseases in clinical practice.3 Herein, we found that optical coherence tomography angiography clearly revealed capillary obliteration of both inner and outer retinal plexuses in an acute Purtscher retinopathy case, although the projection artifact from superficial large vessels were not ideally eliminated. Our findings were consistent with the previous report of a chronic Purtscher retinopathy case.4 Besides, we also detected the disturbance of macular ellipsoid zone from widefield swept-source optical coherence tomography, which might be associated with a poor visual acuity. In conclusion, optical coherence tomography–based multimodal imaging can be used to visualize capillary nonperfusion, quantify foveal avascular zone, and detect ellipsoid zone defect in acute Purtscher retinopathy.

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1. Miguel AI, Henriques F, Azevedo LF, et al. Systematic review of Purtscher's and Purtscher-like retinopathies. Eye (Lond) 2013;27:1–13.
2. Agrawal A, McKibbin MA. Purtscher's and Purtscher-like retinopathies: a review. Surv Ophthalmol 2006;51:129–136.
3. Kashani AH, Chen CL, Gahm JK, et al. Optical coherence tomography angiography: a comprehensive review of current methods and clinical applications. Prog Retin Eye Res 2017;60:66–100.
4. Tokimitsu M, Murata M, Toriyama Y, et al. Delineation of capillary dropout in the deep retinal capillary plexus using optical coherence tomography angiography in a patient with Purtscher's retinopathy exhibiting normal fluorescein angiography findings: a case report. BMC Ophthalmol 2016;16:113.

multimodal imaging; OCT angiography; Purtscher retinopathy

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