Hypertension – August 2016

August 2016

Case Presentation

A 45 year-old was referred to Illinois Retina Associates for a diabetic exam. She had noticed a gradual decrease in vision over the previous two weeks in both eyes.

She was known for diabetes, hypertension, asthma and sickle cell trait. She was on multiple blood pressure medications and insulin.

Examination

Her best corrected visual acuity was 20/40 in the right eye and 20/100 in the left eye. Anterior segment examination was unremarkable. On posterior segment examination, there was bilateral severe optic nerve edema and star-shaped exudates, scattered posterior pole flame-shaped hemorrhages and cotton-wool spots.

Differential Diagnosis

  • Malignant Hypertension
  • Increased intracranial pressure
  • Infectious optic neuropathy
  • Inflammatory optic neuropathy
  • Diabetic papillopathy
  • Sickle cell retinopathy

Diagnostic Testing

Fundus photography showed the optic nerve edema and macular exudation in both eyes (Figures 1 & 2). Suspected macular edema was confirmed with OCT (Figures 3 & 4).

Figure1
Figure 1
Figure2
Figure 2
Figure1
Figure 3
Figure2
Figure 4

Diagnosis

The patient’s blood pressure was checked and found to be 210/150 mmHg. She admitted to not being compliant with her blood pressure medication. The patient was referred to the emergency room for prompt blood pressure control. The patient was diagnosed with hypertensive retinopathy

Follow-Up

Six weeks after achieving blood pressure control, her visual acuity, her visual acuity improved to 20/30 in both eyes, and the macular edema was diminishing without further intervention (Figures 5 & 6).

Figure 5
Figure 5
Figure6
Figure 6

Discussion

Malignant hypertension is defined as blood pressure high enough to cause end-organ damage, typically over 180/120 mmHg. Common fundus findings in patients with malignant hypertension include bilateral optic nerve edema, macular edema, star-shaped macular exudates, cotton-wool spots and retinal hemorrhages. the diagnosis is made by identifying these fundus changes and checking the blood pressure.

Although these findings are commonly found in uncontrolled hypertension, they are non-specific. Therefore, a number of different differential diagnoses need to be considered if the blood pressure is not acutely elevated, including infectious and inflammatory causes, as well as increased intracranial pressure.

Once a diagnosis of malignant hypertension is made, urgent referral for bringing the blood pressure under control is necessary because of the potential life-threatening complications, such as stroke and myocardial infarctions.

References

Hayreh SS, Servais GE, Virdi PS. Fundus lesions in malignant hypertension, V: hypertensive optic neuropathy Ophthalmology.1986;93:74-87.

Luo BP, Brown GC. Update on the ocular manifestations of systemic arterial hypertension. Curr Opin Ophthalmol2004;15:203-210.

Suzuki M, Minamoto A, Yamane K, et al. Malignant hypertensive retinopathy studied with optical coherence tomography.Retina.2005;25:383-384.