1372 A Rare Case of Purtscher's Retinopathy in the Setting of Acute Alcoholic Pancreatitis

Abstract

INTRODUCTION: Purtscher's retinopathy (PUR) is a rare condition first described in 1910. Occlusive microvasculopathy is characterized by sudden visual loss with multiple areas of retinal whitening in the posterior pole. Associated with acute pancreatitis, connective tissue disorders, renal failure, childbirth, bone marrow transplantation. Proteases like trypsin activate the complement system cascade causing coagulation and leukoembolization of the retinal precapillary arterioles. The emboli lodge in the arterioles producing the clinical appearance of PUR with impaired visual acuity and visual field loss. We present a case of a young female with repeat acute pancreatitis who developed sudden visual changes seconday to PUR. CASE DESCRIPTION/METHODS: 28 yo F with PMH of Etoh abuse, gastritis, Mallory-Weiss tear and prior admissions for pancreatitis presented to ED with emesis and abdominal pain for one day. Exam revealed a diffusely tender abdomen. Labs included lipase (939 U/L) (aspartate aminotransferase = 351 U/L, alanine aminotransferase = 179 U/L, alkaline phosphatase = 133 U/L) and hyperbilirubinemia (1.8 mg/dL). Abdominal U/S showed peripancreatic edema correlating acute pancreatitis along with hepatomegaly and steatosis. On day 1 of admission pt complained of visual disturbances upon awakening. Acute visual changes included blurriness, flashes and floaters which completely resolved by the evening. Bedside ophthalmologic exam revealed multiple cotton wool spots bilaterally. Ophthalmology evaluation revealed macular edema and neurosensory detachment of the macula bilaterally secondary to PUR. Visual field testing showed loss of central field bilaterally with preserved peripheral vision. Acuity was 20/200 bilaterally and received intraocular steroid injections with weekly follow up. Exam at 8 weeks demonstrated improvement to visual acuity to 20/40 bilaterally. DISCUSSION: Purtscher Flecken are variable, polyglonal regions of retinal whitening with a clear zone and are pathognomonic. The treatment for the ocular complications of PuR have not been proven and prognosis depends on the areas of the retina that are affected. Isolated case reports have shown rapid improvement in vision with high dose IV steroids. Steroids help preserve the neuronal membrane and suppress granulocyte aggregation caused by complement activation. Patient's complaining of changes in vision following an episode of acute pancreatitis should undergo eye examination in order to rule out Purtscher-like retinopathy.