Purtscher-like retinopathy following total knee arthroplasty
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A 58-year-old gentleman with a past medical history of hypertension underwent bilateral total knee arthroplasty (TKA). Immediately after the operation, he saw a “puzzle-piece missing” in his left eye with no changes to the vision in the right eye. His past ocular history included bilateral photorefractive keratectomy and blepharoplasty. Two weeks later he presented with best-corrected visual acuity of 20/20 in both eyes and normal pressures.

His Dilated fundus exam showed normal optic nerves with multiple cotton wool spots nasal to the fovea in the right eye. The vessels were attenuated. The left eye also had large cotton wool spots superonasal to the fovea with vessel attenuation. The retinal periphery was normal. FA showed several defects including areas of retinal nonperfusion corresponding to the cotton wool spots. Spectral-domain optical coherence tomography (SD-OCT) showed nerve fiber layer infarcts and accumulation of axoplasmic material at the cotton wool spots, but no fluid or exudation. He was observed, and two months later stated that the missing “puzzle piece” was resolving. His vision remained stable at 20/20. Fundus exam showed resolution of the cotton wool spots and Spectral-domain optical coherence tomography demonstrated resolution of nerve fiber layer infarcts and axoplasmic accumulation at the areas of cotton wool spots.

Purtscher-like retinopathy can occur immediately following total knee arthroplasty. Factors including fatty acid liberation, endothelial damage, aberrant coagulation cascade activation, leukocyte aggregation, embolic vascular occlusion, and microinfarction are likely contributing factors. When patients undergo knee arthroplasty and complain of visual scotomas, the diagnosis of Purtscher-like retinopathy should be considered with a referral for careful ophthalmic examination and work-up.