Case Description

•  ID •  25 year old man with history of alcohol abuse

presented with acute necrotizing pancreatitis.

•  HPI •  Acute onset of epigastric pain, nausea, vomiting

and elevated lipase. •  Development of pseudocyst, paracolic fluid, pleural

effusion, mild pericardial effusion, acute tubular necrosis requiring hemodialysis.

•  ROS •  Blurry vision and decreased ability to see faces

with onset of abdominal pain.

•  PE •  OD 20/160, OS 20/250 •  Dilated fundus exam: cotton wool spots,

peripapillary hemorrhages, and mild macular edema

•  Hospital Course •  Developed hemorrhagic phlegmon and PEA arrest

following blood transfusion. •  Pancreatitis resolved and discharged after two

months hospital stay with continued outpatient hemodialysis.

•  No further documentation regarding vision changes or improvements noted prior to discharge.

Discussion

•  Epidemiology

•  0.24 persons per 1 million •  Up to 10 percent of acute pancreatitis

•  Pathogenesis •  Complement activation embolic phenomena

vascular occlusion of retinal arterioles

•  Clinical and Objective findings •  Asymptomatic to significant visual loss •  “Purtscher flecken”, cotton wool spots, retinal

hemorrhages or macular edema

•  Management •  Supportive approach initially •  Limited data support IV and then PO steroids

•  Lessons •  Recognize and diagnose rare complication

associated with pancreatitis •  Provide counseling for potentially distressing

symptom •  Role for medical treatment if no spontaneous

resolution

• Recognize Purtscher Retinopathy as an uncommon complication of acute pancreatitis.

• Understand the epidemiology, pathogenesis, clinical findings and management of Purtscher Retinopathy.

Learning Objectives

References

    

Images

Purtscher Retinopathy: An Eye On Acute Pancreatitis

1) Mayer C, Khoramnia R.  Purtscher‐like re;nopathy caused by acute pancrea;;s Lancet 2011; 378: 1653 2) Carrera CR, Pierre LM, Medina FM, Pierre‐Filho Pde T.  Purtscher‐like re;nopathy associated with acute pancrea;;s. Sao Paulo Med J. 2005 Nov 3;123(6):289‐91. 3) Agrawal A, McKibbin M. Purtscher's re;nopathy: epidemiology, clinical features and outcome. Br J Ophthalmol. 2007 Nov;91(11):1456‐9. 4) Bhan K, Ashiq A, AralikaZ A, Menon KV, McKibbin M. The incidence of Purtscher re;nopathy in acute pancrea;;s. Br J Ophthalmol. 2008 Jan;92(1):151‐3 5) Agrawal A, McKibbin MA. Purtscher's and Purtscher‐like re;nopathies: a review.  Surv Ophthalmol. 2006 Mar‐Apr;51(2):129‐36. 6) Shapiro I, Jacob HS.  Leukoemboliza;on in ocular vascular occlusion. Ann Ophthalmol. 1982 Jan;14(1):60‐2 7) Holak HM, Holak S. Prognos;c factors for visual outcome in purtscher re;nopathy.Surv Ophthalmo. 2007 Jan‐Feb;52(1):117‐8; author reply 118‐9. 

Tin Nguyen MD1; Eleanor Loomis MD, MPH2; Raja Jagadeesan MD, MS, MPH2,3

Family Medicine1 and Internal Medicine2 Residency Programs, UC Davis School of Medicine Sacramento VA Hospital3

Purtscher Retinopathy: Uncommonly Recognized Complication of Acute Pancreatitis

Figure 1 and 2: Bilateral dilated fundoscopic exam illustrating cotton wool spots, peripapillary

hemorrhages and mild macular edema consistent with Purtscher Retinopathy.

Figure 1 Figure 2

Commonly Recognized Complications of Acute Pancreatitis

Figure 3: Acute Walled Off Necrotic

Fluid Collections

Figure 4: Hemorrhagic Phlegmon

Figure 5: CT – Pleural Effusion Figure 6: CXR -Pleural Effusion