Sir,

Purtscher's like retinopathy is a rare complication arising in patients with an established diagnosis of pancreatitis. We report a patient, with undiagnosed pancreatitis, presenting with visual loss due to Purtscher's like retinopathy.

Case report

A 31-year-old man with a history of alcohol abuse, experienced bilateral visual loss, following 24 h of epigastric pain and vomiting, precipitated by binge drinking. On presentation, 4 days later, he had a right relative afferent pupil defect and visual acuity (VA) of counting fingers right and 6/24 left. Retinal examination revealed bilateral posterior pole cotton wool spots (CWS) and right retinal and preretinal haemorrhages, consistent with Purtscher's like retinopathy (Figure 1). Blood tests revealed a raised C-reactive protein (CRP) at 20 mg/l, raised alanine transaminase at 118 IU/l (<35), a reduced platelet count at 73 × 109/l (140–400) and a normal serum amylase. Acute alcoholic pancreatitis was diagnosed.

Figure 1
figure 1

Right and left fundi at presentation.

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Fluorescein angiography revealed masking from retinal haemorrhage and CWS, nonperfusion of small arterioles in the macular region, perivenous staining and venous dilatation and leakage (Figure 2).

Figure 2
figure 2

Early and late fluorescein angiograms of right eye at presentation.

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After 7 weeks, his VA was 6/9 right and 6/6 left, with resolution of most retinal signs.

Comment

This patient's pancreatitis may have remained undiagnosed had he not developed Purtscher's like retinopathy. Pancreatitis was suspected based on the ophthalmic findings and the diagnosis was supported by the history, epigastric tenderness, raised CRP, and low platelets.1 His serum amylase was normal because the test was performed 5 days after the onset of symptoms and levels can normalise within 3 days.2

As in this case, pancreatitis complicated by Purtscher's like retinopathy is usually alcohol related,3 with few reported exceptions.4, 5 One may hypothesise that alcohol could potentiate the complement activated, leukoembolisation of retinal arterioles, thought to be responsible for the clinical picture of Purtscher's like retinopathy.6

This patient had mild pancreatitis, supporting the observations of others, that the development of Purtscher's like retinopathy is unrelated to the severity of pancreatitis.7

We believe this to be the first report of pancreatitis being diagnosed as a direct result of a patients presentation to an ophthalmologist with Purtscher's like retinopathy.