Bilateral Purtscher-Like Retinopathy With Profound Macular Ischemia and Vision Loss in Severe Pre-Eclampsia

Abstract

Purtscher-like retinopathy is an extremely rare condition in patients with pre-eclampsia. The bilateral vision loss as seen in the current case is infrequent, but devastating. Our patient is a 27-year-old healthy primigravida patient with severe pre-eclampsia undergoing uncomplicated cesarean section due to abnormal kidney function and worsening hypertension. Postoperatively, she developed Purtscherlike retinopathy with profound macular ischemia and count-finger only vision. Neuroimaging was unrevealing. Her postoperative course was significant for hyponatremia, acute kidney injury, ileus, pancreatitis, leukocytosis, and postoperative fevers with suspected septic pelvic thrombophlebitis. The resultant visual acuity overall improved, but remained limited to 20/150 and 20/250 at 3 months postpartum. Purtscher-like retinopathy in the setting of pre-eclampsia can result in vision loss even in the absence of findings on neuroimaging or presence of HELLP syndrome.

Case Report: Postpartum Purtscher-like Retinopathy

“…Swelling of the optic disc and retinal edema can also be present; however, these findings are much less common. Most cases are bilateral 4 . In the limited number of cases studied, only 50% of patients return to baseline vision 5…”

“…Most cases are bilateral. 4 In the limited number of cases studied, only 50% of patients return to baseline vision. 5 Purtscher retinopathy is classically caused by occlusive microvasculopathy associated with head trauma.…”

“…The pathophysiology of Purtscher-like retinopathy is not fully understood; however, it is thought to be caused by underlying systemic disease 6 and embolization that results in occlusion of arterioles and ischemia of the retina. 4,6 The complications from Purtscher and Purtscher-like retinopathy are caused by arteriolar occlusion. In trauma, the complement system is commonly activated, which can cause complement-activated leukocyte aggregation.…”

“…The overall recommendation is to treat the underlying systemic cause when possible. 2,4,6,10 In most cases, spontaneous visual recovery is varied and does not return to normal baseline in about 50% of patients. When retinopathy clears, vessel attenuation, temporal disc pallor, and mottling of the retinal pigment epithelium commonly inhibit a full visual recovery.…”

“…Purtscher-like retinopathy can be caused by nontraumatic etiologies, such as pancreatitis, hemolytic uremic syndrome, connective tissue diseases, and pregnancy/childbirth. The pathophysiology of Purtscher-like retinopathy is not fully understood; however, it is thought to be caused by underlying systemic disease 6 and embolization that results in occlusion of arterioles and ischemia of the retina 4,6 …”