A 24-year-old man sustains severe blunt chest trauma in a road traffic accident. Two days later he reports blurred vision. Fundoscopy shows numerous cotton wool spots and superficial haemorrhages clustered around both optic discs, with distinctive greyish-white patches situated between the retinal arterioles and venules. The most likely diagnosis is:

• A Valsalva retinopathy
• B Commotio retinae
• C Purtscher retinopathy ✓
• D Terson syndrome

Explanation

Purtscher retinopathy follows major trauma to the head, chest or long bones, or acute pancreatitis. Complement activation generates leucoemboli that occlude precapillary arterioles, causing cotton wool spots, haemorrhages and the pathognomonic Purtscher flecken, grey polygons lying between arterioles and venules around the optic disc. Valsalva retinopathy shows only premacular haemorrhage from raised venous pressure, commotio requires direct ocular contusion, and Terson syndrome accompanies subarachnoid haemorrhage.

Reference: Kanski's Clinical Ophthalmology, 9th ed.

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Written and medically reviewed by the StethoPrep medical team.