MII Retcam Assisted Documentation of Unilateral Angiopathia Retinae Traumatica in a Three Year Old

Abstract

Purtscher's retinopathy is characterized by sudden vision loss following severe head trauma. Signs of ischemia are visible at the posterior pole with edema and hemorrhages concentrated around the optic disc. Digital imaging with retcam is more precise in diagnosing but is not easily available or affordable. Smartphones have thus, emerged as an alternative and reliable imaging tool. The aim of this study is to illustrate the utility of MII RetCam assisted smartphone based fundus imaging in registering and monitoring Purtscher's retinopathy. Good documentation helps in better communication with the patient and relatives and improves their compliance with treatment.

INTRODUCTION

Purtscher's retinopathy is an occlusive vasculopathy seen in cases of severe head trauma. Sudden blindness with multiple areas of retinal whitening and hemorrhages is seen.[¹] Examining the ocular fundi of younger children is more difficult. Digital imaging with RetCam is quite precise but is costly. Smartphones are therefore emerging as an alternative imaging tool. Lin et al.[²] was the first to report the utility of smartphone imaging in Retinopathy of Prematurity (ROP). In India, a smartphone-based device "Make In India (MII) Ret Cam" was first described in ROP.[³]

Here, we aim to illustrate the utility of MII RetCam in the documentation and monitoring of Purtscher's retinopathy which has not been done earlier.

CASE REPORT

A 3 year old girl got admitted to pediatric emergency after she met with an accident where a bus flipped over in which she was traveling and she got stuck between the front and rear seats of the bus. This was followed by loss of consciousness with Glassgow coma scale[⁴] of E1V1M4, respiratory rate was high with gasping efforts although the oxygen saturation (SpO₂) was 85%; marked facial cyanosis and edema, abnormal body movements with tonic posturing was present. No history of oral, nasal, or ear bleeding was seen. She was intubated and kept on ventilator support. On CT scan examination of the head and neck, there was a bilateral medial wall fracture of the maxillary bone along with associated bilateral haemosinus.

On ocular examination, a relative afferent pupillary defect (RAPD) in the right eye with bilateral subconjunctival hemorrhages in all quadrants and bilateral profuse eyelid swelling was present. Vision could not be assessed on the day of admission. Fundus examination using MII RetCam-assisted smartphone-based fundus camera (MSFI) revealed multiple retinal white patches with retinal hemorrhages and right-sided disc edema whereas left eye fundus examination was normal [Figures 1 and 2]. After the child was weaned off from the oxygen support, the fundus was re-evaluated in Eye out-patient department (OPD) and the findings of multiple retinal infarcts and hemorrhages were stamped as Purstcher's retinopathy in the right eye. Visual Evoked Potential (VEP) was advised but could not be done as the child could not fix her gaze.

Figure 1: (a) The technique of imaging the eyes using the smartphone-based device (MII Retcam). (b) MII Retcam device used in this study

Figure 2: Fundus images captured using smartphone–based fundus camera device (MII RetCam) and +20 D lens showing. (a) Multiple areas of retinal whitening and retinal hemorrhages alongwith disc edema in the right eye. (b) Normal fundus in the left eye

DISCUSSION

Purtscher's retinopathy, also known as angiopathy retinae traumatic, was first described by Otmar Purtscher in 1912 following a head injury.[¹] The pathogenesis is still uncertain and may be due to more than one initiating factor. The most accepted mechanism is the Complement C5a-mediated hypothesis. The C5a induces the formation of leukocyte, platelet, and fibrin aggregate that causes retinal embolization and ischemia and the development of Purtscher's.[⁵]

Patients may experience sudden vision loss either immediately or within 48 hours of the event. It is bilateral in 60% of cases.[¹] The most commonly seen fundoscopic signs are cotton-wool spots, retinal hemorrhages, and Purtscher flecken pertaining to the posterior pole only.[⁶] The disc may initially appear normal but RAPD may be present and optic disc pallor may develop in the later stages. The flecken and the hemorrhages may resolve over several months, and the cause of residual vision loss may be due to optic atrophy.[⁷] In our case, similar findings were seen in the right eye of the patient. We managed to document the findings using a portable fundus camera (MSFI) which has never been used before in younger children for diagnosing Purtscher's retinopathy.[³] The modern smartphone camera is equipped with a high-quality optical system that can be used to capture good-resolution retinal images. In addition, this smartphone-assisted device can prove to be of great benefit in hospitals where sophisticated imaging modalities are not available, which is a very common scenario in a developing country like India. It is not only cost-effective but also convenient to use. Its use can be explored in childhood diseases other than ROP, especially in trauma where medicolegal documentation is of utmost priority. Serial recordings during follow-up visits can help to objectively monitor the disease.

Currently, there are no definite guidelines for the treatment. Wang et al.[⁸] reported a case of corticosteroid use in a patient that showed a good visual response within the first two weeks. However, Miguel et al.[⁶] stated no statistically significant difference between visual acuity (VA) improvement for patients treated with corticosteroids compared with observation. They concluded that observation and treatment of the underlying etiology is the most reasonable therapeutic option without the risk of adverse drug effects. In our case, we kept our patient under observation and the ocular findings of the right eye started resolving in a few months.

CONCLUSION

Our case illustrates a rare but clinically significant ocular involvement in a young child with a history of trauma using the MII RetCam-assisted device. There have been many studies done in the area of ROP with this device but no article published in the literature so far using this device to report Purtscher's retinopathy in the younger age groups. A fundoscopic examination in mydriasis is obligatory in such patients who come with a history of trauma. The study emphasizes on the importance of the handheld smartphone-based fundus photography in routine trauma cases in children as it helps decrease the technical barrier for image acquisition in the paediatric population.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.