Bilateral whitish lesions in the fundus of a young male.

A 32-year-old gentleman who is a known case of alcoholism and renal dysfunction presented with sudden painless blurred vision in both eyes (OU) for 6 days. There was no history of trauma. Blood pressure was 130/80 mm Hg. Visual acuity was 6/36, N10 in the right eye (OD) and 6/24, N8 in the left eye (OS). On examination, OU anterior segment was normal with reactive pupils. Dilated fundus examination revealed bilateral multiple yellowish-white fluffy lesions along the attenuated vessels and a few scattered intraretinal hemorrhages [Fig. 1a]. Optical coherence tomography (OCT) revealed intraretinal and macular edema with cystic spaces and areas of neurosensory detachment [Fig. 1b and c].

Figure 1

(a) Color fundus photograph of the right eye and left eye showing multiple yellowish-white fluffy lesions along the attenuated vessels and a few scattered intraretinal hemorrhages. OCT (b) right eye and (c) left eye showing intraretinal and macular edema with cystic spaces and areas of neurosensory detachment. (d) Color fundus photograph of the right eye and left eye after a month of initial presentation showing resolution of Purtscher-flecken. OCT (e) right eye and (f) left eye showing complete resolution of intraretinal and macular edema

What will you do next?

Contrast-enhanced MRI brain and orbits

Start intravenous antibiotics

Check renal function tests and immediate nephrology referral

OCT angiography.

Findings

As there was a prior history of renal dysfunction, renal function tests were done, which were deranged (urea: 123 mg/dl; creatinine: 11.26 mg/dl). Hemodialysis was done under nephrologist guidance. Acute interstitial nephritis was made out on renal biopsy. The yellowish-white polygonal lesions are Purtscher-flecken, which in the absence of a history of trauma, point toward a diagnosis of Purtscher-like retinopathy.[1] Topical nepafenac eye drops were prescribed thrice daily in both eyes.[2] Post dialysis, there was a gradual improvement in the visual acuity (OD 6/9, N6; OS 6/6, N6) and resolution of Purtscher-flecken after a month [Fig. 1d]. OCT also revealed complete resolution of intraretinal edema [Fig. 1e and f]. A prompt diagnosis of the systemic condition and its management is critical in early recovery.

Diagnosis

Purtscher-like retinopathy.

Correct answer: C.

Discussion

Purtscher-like retinopathy is a rare vision-threatening microangiopathy secondary to complement-mediated leukoembolization and subsequent infarction of the retinal capillary bed.[3] History of trauma is typically absent, which differentiates it from a classical Purtscher retinopathy. Various causes include renal failure, pancreatitis, Valsalva maneuver, fat/air/amniotic embolism, connective tissue disorders, myocardial infarction, hematopoietic disorders, preeclampsia, HELLP syndrome, and post-viral and post-surgery illness. There is no proven standard therapy. Management of the causative pathology is vital. Therapeutic options described in the literature include pulse and oral steroids, NSAIDs, intravitreal anti-vascular endothelial growth factor agents, monoclonal antibodies, and proteasome inhibitors.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.