Development of Purtscher-like retinopathy after pre-eclampsia combined with acute pancreatitis
A 33-year-old primigravida was transferred to the Kyung Hee University Medical Center for preterm labor and pre-eclampsia at 36+4 weeks gestation. She had a twin pregnancy after in vitro fertilization-embryo transfer. Her blood pressure measured 140/100 mm Hg. Her urine protein was 4+ and 24-hour urinary protein excretion was 2,333 mg/day. She did not have headache, visual disturbances, or pitting edema. She had regular uterine contractions and a cervix dilated about 2 cm. An emergency cesarean section was performed uneventfully, and healthy twin babies were born.\nOn the second postoperative day, the patient had abdominal distension, steady epigastric and whole abdominal pain. An abdominal X-ray examination showed paralytic ileus. Laboratory examination showed white blood cell (WBC) count of 11,890, low Ca+ of 6.4 mg/dL, elevated blood urea nitrogen (BUN) of 64 mg/dL, serum creatinine of 1.5 mg/dL, aspartate transaminase (AST) of 52 IU/L, alanine aminotransferase (ALT) of 21 IU/L, elevated C-reactive protein (CRP) of 20.74 mg/dL, triglyceride 1,080 mg/dL and otherwise non-specific. At that time, she started complaining of blurry vision. Because pre-eclampsia-related visual disturbances are common, we did not perform a formal ophthalmic examination. We decided on conservative management including nasogastric drainage, parenteral nutrition, non per os, pain control, and avoidance of toxic renal medications.\nOn the fifth postoperative day, the patient had flank pain, diarrhea, tachycardia (pulse 112 per minutes) and fever (38℃). Laboratory examination showed WBC count of 14,900, low Ca+ of 5.6 mg/dL, AST of 61 IU/L, ALT of 33 IU/L, elevated CRP of 8.56 mg/dL, and normalized BUN and serum creatinine. Bacterial cultures were taken from blood and urine, and antibiotics were started. Her visual loss was equivocal.\nThe patient still had epigastric pain, a fever (38.3℃) and visual loss in both eyes until eight days after operation. At this point, we therefore decided to do an abdominal computed tomography (CT) scan and an ophthalmology consultation. The abdominal CT scan showed enlargement of pancreas with fat infiltration, fluid collection in the pancreatic area and no other abnormal findings. Serum amylase and lipase levels were elevated at 149 U/L (normal range, 25 to 125 U/L), and 128 U/L (normal range, 5.5 to 58 U/L) respectively, on the day of CT scan. The patient was diagnosed as having acute pancreatitis based on her steady epigastric pain and abdominal CT scan. She recovered fully upon resolution of pancreatic necrosis with conservative management and drainage of the underlying fluid collection.\nOn the same day, the patient underwent an ophthalmologic examination, and her visual acuity test was 0.02 (right) and finger count 30 cm (left). There were multiple discrete retinal changes, and macular yellow patches, known as Purtscher flecken, in both eyes. A retinal splinter hemorrhage was seen in the right eye upon retinal photography (). A fluorescein angiogram showed arteriolar occlusion, and retinal ischemia, typical signs of Purtscher-like retinopathy. She was diagnosed with Purtscher-like retinopathy based on her symptoms and the results of the ophthalmologic examinations. Because there are no definite guidelines for the treatment of this condition, her visual acuity was closely monitored with conservative management. We also performed a brain magnetic resonance imaging (MRI) to rule out cortical blindness. The brain MRI showed unremarkable findings (). Two months after onset of visual loss, her visual acuity test was 0.08 (right) and 0.01 (left) and the multiple yellowish patches had decreased in both eyes on retinal photographs. At a recent follow-up (two years after the onset of her visual symptoms), her corrected visual acuity was 0.2 (right) and 0.1 (left). There was gradual improvement in the visual functions of both eyes, but she still had visual impairment.