NEWS & EVENTS
Retinal Review, Issue 24
CASE NUMBER 24
A 37 year old man was referred for retinal hemorrhaging and vision loss. He reported no past ocular or medical history. He was born in India and had been living in America for 10 years. He has a family history of a father with hypertension diagnosed in his 50’s. He noted gradual vision loss OS>OD for the past three weeks. He was also experiencing headaches and loss of appetite. On examination, he appeared pale and weak. Visual acuity measure OD: 20/100 and OS: 20/200. IOP’s were normal OU as was the SLE. Dilated examination:
Fundus examination is significant for optic nerve edema, multiple retinal hemorrhages, cotton wool spots, and geographic areas of RPE disturbance (Elschnig spots). Fluorescein angiography confirms the multiple hemorrhages and exudates and demonstrates moderate ischemia. Differential diagnosis includes malignant hypertension vs rapidly progressive diabetic retinopathy, or combination of both. We measured the blood pressure in the office at an impressive 290/140. We sent the patient to the local hospital emergency room for immediate attention due to the risk of stroke.
The initial treatment for hypertensive retinopathy is normalization of the blood pressure. After the blood pressure has normalized and several weeks or months have passed, if there is still retinal hemorrhaging or ischemia, treatment can be considered. Treatment can include laser photocoagulation or anti VEGF injections. Even if all hemorrhaging and exudation resolve there can still be permanent vision loss due to optic nerve or retinal ischemia. Our patient was hospitalized for two weeks. The hospital course was significant for a gradual improvement in blood pressure. Unfortunately he suffered numerous ministrokes while he was hospitalized, likely due to poor cerebral perfusion from the lowering of his blood pressure. His blood sugar was never elevated. He also was diagnosed with kidney failure due to the hypertension. His creatinine level was 6.0, with approximately 20% kidney function.
He returned to us for his follow up visit one week after discharge from the hospital reporting slight improvement in his vision. Blood pressure was 140/85 on multiple medications. Visual acuity measured OD: 20/40 and OS: 20/100. Dilated examination:
There was a slight improvement in the optic nerve swelling and retinal vasculopathy. Observation is still warranted. The patient will return for follow up examinations monthly. If after several months there is persistent hemorrhaging, exudation or ischemia, ocular treatment will be considered. The vision will likely continue to gradually improve but will not likely return to normal.