INTRODUCTION

Purtscher retinopathy (PuR) is a rare complication of chest compression trauma [1]. Purtscher [2] first described this condition in 1910 when a middle-aged man experienced retinopathy caused by falling onto a tree. Most cases of PuR are trauma-induced, with chest compression trauma being particularly notable [3]. The incidence of PuR is approximately 0.24 cases per million people annually [1]. A common clinical symptom is abrupt visual field loss, which often manifests as central, paracentral, or arcuate scotomata [4]. In severe cases, visual acuity may decline to only having the ability to count fingers. PuR may be missed or remain asymptomatic if physicians fail to conduct thorough history-taking and comprehensive physical examinations [3]. Generally, PuR carries a good prognosis; however, progressive and persistent retinal changes in the month following trauma may signal a deteriorated visual outcome [1].

CASE REPORT

Patient information

A 56-year-old man presented to the trauma resuscitation unit after being struck by a 1-t truck. The accident involved the truck hitting the patient against a wall. The truck was retrieved promptly. Although the patient did not lose consciousness, he experienced shortness of breath for a minute after the impact.

Clinical findings and timeline

Upon arrival, the patient exhibited right chest contusions, pain, and tenderness. His mental status was alert and his vital signs were within normal limits. No evidence of head injury or asphyxia was reported. The patient had well-controlled hypertension and minimal change disease.

Diagnostic assessment

Chest computed tomography confirmed multiple rib fractures involving the right third and sixth to ninth ribs.

Therapeutic intervention

The patient was admitted for close observation and remained stable without complications in the general ward. However, during a tertiary survey conducted 24 hours after hospitalization, he reported decreased vision in his right eye. An ophthalmological evaluation was promptly performed. Visual acuity was 20/50 in the right eye and 20/25 in the left eye. On performing optical coherence tomography, the right eye showed characteristics specific to PuR, including retinal thickening, edema, and serous detachment at the inner layer, along with hyperreflective band lesions at the inner nuclear layer level (Fig. 1). Fundoscopy revealed intraretinal hemorrhage in the right eye. Additionally, fluorescein angiography revealed reduced blood flow in the both deep and inner retinal vascular plexuses. Furthermore, a honeycomb-like decreased hypointensity signal pattern was observed in the choriocapillaris (Fig. 2). The patient had no relevant ophthalmological history.

Follow-up and outcomes

Outpatient follow-up with conservative treatment was planned. At an outpatient visit 11 days after discharge, the patient’s symptoms improved, and he had a visual acuity of 20/20 in both eyes. Fundoscopy showed an improvement in the intraretinal hemorrhage, reduced retinal thickening and edema, and improved serous detachment at the inner layer compared with that at the previous examination (Fig. 3A). Further, optical coherence tomography revealed an improvement in the hyperreflective band lesions at the inner nuclear layer level (Fig. 3B).

Ethics statement

This study was approved by the Institutional Review Board of the National Medical Center, with a waiver of informed consent due to its retrospective nature (No. NMC-2024-05-045).

DISCUSSION

The pathogenesis of PuR remains unclear [5]. One of the most likely explanations for developing PuR is the deterioration of microvascular circulation, causing occlusion and ischemia. PuR is often triggered by increased intrathoracic and intracranial pressures, that cause venous system reflux and lymph extravasation [4,5]. It could also be explained by the vascular emboli caused by air, fat, fibrin, platelets, leukocytes, and complement activation. Additionally, free fatty acid-induced vasculitis can result in PuR [4]. In our patient, increased intrathoracic pressure due to chest compression likely precipitated PuR.

PuR typically manifests 24 to 48 hours after a causative event [4]. Pathological findings of PuR include cotton wool spots, Purtscher flecken, and retinal hemorrhages [4,6]. Although intravenous steroids or steroid injections into the vitreous body have been used to treat PuR, no treatment has been definitively proven as optimal [6–8].

Trauma teams often encounter diagnostic challenges when managing posttraumatic complications, such as PuR, which are not the direct impacted site of injury. This condition may not spontaneously develop, especially in cases without evident head trauma or asphyxia. Therefore, a comprehensive examination of multiple areas, rather than just the site of impact, is essential.

A tertiary survey first introduced by Enderson et al. [9] has been proven to reduce missed injury rates in patients with major trauma. The tertiary survey involves the process of identifying and cataloging all injuries within the first 24 hours of hospitalization following the secondary survey [10]. This process has been shown to reduce delayed diagnoses in patients with major trauma [11,12]. Therefore, traumatologists should thoroughly examine even seemingly minor patient injuries, attentively listen to and assess their symptoms, and conduct meticulous tertiary surveys. This case emphasizes the importance of completing a thorough tertiary survey to detect potential posttraumatic consequences.

ARTICLE INFORMATION

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Author contributions

Conceptualization: MUJ, YK; Investigation: MUJ, HGJ; Methodology: HGJ, YK; Project administration: MUJ, YK; Resources: HGJ, YK; Supervision: HGJ, YK; Validation: HGJ, YK; Visualization: MUJ, YK; Writing–original draft: MUJ; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Additional information

The abstract of this article was presented at the 11th Pan Pacific Trauma Congress 2024 Korea on June 13–14, 2024, in Suwon, Korea.

Fig. 1.

Optical coherence tomography scan. (A) Retinal thickening, edema, and serous detachment at the inner layer. (B) Hyperreflective band lesions at the inner nuclear layer level.

Fig. 2.

Fluorescein angiography image. (A) Intraretinal hemorrhage is observed in the right eye. (B) Reduced blood flow in both the deep and inner retinal vascular plexuses, accompanied by a decreasing honeycomb-like intense signal pattern at the choriocapillaris layer, is shown.

Fig. 3.

Images of the right eye 11 days after discharge. (A) The fundoscopic examination results show that the intraretinal hemorrhage had remarkably decreased. (B) Optical coherence tomography reveals reduced retinal thickening, edema, and serous detachment at the inner layer compared with that at the previous examination, along with improvement in the hyperreflective band lesions at the inner nuclear layer level.

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Figure & Data

References

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