Purtscher's Retinopathy After Cardiopulmonary Resuscitation: A Literature Review

Abstract

Purtscher's retinopathy is a rare angiopathy reported in patients with a history of severe trauma and other systemic diseases. The diagnosis is made on clinical grounds, and the severity varies. A 41-year-old gentleman with underlying poorly controlled diabetes mellitus and dyslipidemia was referred to the ophthalmology department for diabetic retinopathy screening. He denied visual complaints. Ocular examination revealed a negative relative afferent pupillary defect with a visual acuity of 6/6 bilaterally. The anterior segment examination was unremarkable. Both eye (oculus uterque, OU) fundus revealed a pink disc with a cup-to-disc ratio of 0.4 and peripapillary flame-shaped hemorrhages. Right eye (oculus dexter, OD) also showed multiple cotton wool spots along the superotemporal arcade involving zones 1 and 2 of the retina, while left eye (oculus sinister, OS) showed a single cotton wool spot along the superotemporal arcade at zone 1 of the retina. Otherwise, there were no visible retinal emboli, dot hemorrhages, or hard exudates, and the macula was normal. The retinal features were not characteristic of diabetic retinopathy. It mimicked hypertensive retinopathy, but the patient was normotensive. The absence of inner retinal thickening and hyperreflectivity on optical coherence tomography of the macula ruled out retinal vein occlusion. This prompted us to elicit further history, and the patient disclosed a recent admission for myocardial infarction in which he received cardiopulmonary resuscitation with chest compressions for seven minutes. Hence, the diagnosis of OU Purtscher's retinopathy was made, and the patient was monitored closely in the clinic. Purtscher's retinopathy remains a diagnostic dilemma and should not be neglected in complex clinical contexts.

Keywords: cardiac resuscitation; chest compression; cotton wool spot; purtscher's retinopathy; retinal hemorrhages; traumatic retinal angiopathy.

Figure 1. OU photo on presentation.

A: OD fundus showing a pink disc with a cup-to-disc ratio of 0.4 with peripapillary flame-shaped hemorrhages (blue arrow) and multiple cotton wool spots (black arrow) along the superotemporal arcade involving zone 1 and 2 of the retina. B: OS fundus showing a pink disc with a cup-to-disc ratio of 0.4 with peripapillary flame-shaped hemorrhages (blue arrow) and a single cotton wool spot (black arrow) along the superotemporal arcade at zone 1 of the retina. OU: oculus uterque, OD: oculus dexter, OS: oculus sinister.

Figure 2. OU optical coherence tomography (OCT) of the macula on presentation.

A: OD OCT macula showing a normal foveal contour with the absence of intraretinal fluid or hyperreflective foci. B: OS OCT macula showing a normal foveal contour with the absence of intraretinal fluid or hyperreflective foci. OU: oculus uterque, OD: oculus dexter, OS: oculus sinister.

Figure 3. OU fundus photo six months post-presentation.

A: OD fundus showing a pink disc with a cup-to-disc ratio of 0.4 and minimal residual cotton wool spots along the superotemporal arcade involving zone 1 of the retina. B: OS fundus showing a pink disc and a cup-to-disc ratio of 0.4 with resolved hemorrhage and cotton wool spots. OU: oculus uterque, OD: oculus dexter, OS: oculus sinister.