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\begin{document}

\title{Unilateral Purtscher-like retinopathy as the presenting feature of a
case with spontaneous carotid artery dissection}



\author[1]{Şefik Can İpek}%
\author[2]{Aylin Yaman}%
\author[2]{Süleyman Men}%
\author[2]{Ali Osman Saatci}%
\affil[1]{Affiliation not available}%
\affil[2]{Dokuz Eylul Universitesi Tip Fakultesi}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\begin{abstract}
Carotid artery dissection should be considered in the differential
diagnosis when a clinician face with a case presenting with an
unilateral Purtscher-like retinopathy.%
\end{abstract}%



\sloppy


\textbf{Unilateral Purtscher-like retinopathy as the presenting feature
of a case with spontaneous carotid artery dissection}

\textbf{Keywords:} Dissection, internal carotid artery, Purtscher
retinopathy.

\textbf{Key Clinical Message}

Carotid artery dissection should be considered in the differential
diagnosis when a clinician face with a case presenting with an
unilateral Purtscher-like retinopathy.

\textbf{Case description}

A 64-year-old man with type 2 diabetes was examined with a severe
headache and mild visual acuity decrease in his right eye. On
examination, his best-corrected visual acuity was 20/30 in his right eye
and 20/20 in the left. While left fundus was normal, there was
peripapillary cotton-wool spots with an intact foveal architecture in
his right eye (Figure 1). A diagnosis of right Purtscher-like
retinopathy was made. A detailed systemic workup was carried out and
right internal carotid artery catheter angiography demonstrated the
presence of the spiral dissection of right internal carotid artery
(Figure 2). The diagnosis of Purtscher-like retinopathy is clinical with
a presentation that usually includes sudden unilateral or bilateral
visual disturbance of variable severity. It is characterized with
several retinal findings, such as cotton-wool spots, retinal
hemorrhages, and areas of inner retinal whitening namely Purtscher
flecken. A multitude of various systemic diseases has been described as
the cause.\textsuperscript{1} Very recently Qazi et
al.\textsuperscript{2} reported a 40-year-old woman with an unilateral
Purtscher-like retinopathy. Two days earlier, she had an ischemic stroke
of her middle cerebral artery secondary to a right carotid artery
dissection. Whenever a diagnosis of Purtscher-like retinopathy is made,
underlying diseases should be scrutinized meticulously.

\textbf{Legends}

Figure 1- Right eye;

\begin{enumerate}
\tightlist
\item
  Color fundus picture showing the scattered peripapillary cotton-wool
  spots with notingly normal looking fovea.
\item
  Arteriovenous phase of fluorescein angiogram depicting the
  hypofluorescent spots corresponding to the cotton-wool spots.
\item
  Horizontal spectral domain optical coherence tomographic frame through
  one of the cotton wool spots delineating the increased reflectivity of
  the ganglion cell layer.
\end{enumerate}

Figure 2- Right internal carotid artery catheter angiography shows
long~segment dissection. The start and end points of the dissection are
pointed by the arrows. As the dissected intima follows a spiral route,
the true (flowing) lumen shows an undulating pattern.

\textbf{Author contribution:}

SCI- Involved in writing of the manuscript.

AY and AOS- Involved in the ophthalmological examination and editing of
the manuscript.

SM- Involved in the neuroradiological examination.

\textbf{Conflict of interest:} None declared.

\textbf{References}

1. Miguel AIM, Henriques F, Azevedo LFR, Loureiro AJR, Maberley DAL.
Systematic review of Purtscher's and Purtscher-like
retinopathies.\emph{Eye} . 2013;27(1):1-13.

2. Qazi S, Palakkamanil MM, Sia DIT, Ehmann DS. Carotid artery
dissection associated with Purtscher-like retinopathy. \emph{Can J
Ophthalmol} . 2020;55(2):e77-e79.\selectlanguage{english}
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