Oman Journal of Ophthalmology

CLINICAL QUIZ
Year
: 2020  |  Volume : 13  |  Issue : 3  |  Page : 176--177

3D: Decreased vision, dizziness, and disc edema


Ramanuj Samanta, Athul S Puthalath, Neeraj Saraswat, Ajai Agrawal 
 Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Correspondence Address:
Dr. Ramanuj Samanta
Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India




How to cite this article:
Samanta R, Puthalath AS, Saraswat N, Agrawal A. 3D: Decreased vision, dizziness, and disc edema.Oman J Ophthalmol 2020;13:176-177


How to cite this URL:
Samanta R, Puthalath AS, Saraswat N, Agrawal A. 3D: Decreased vision, dizziness, and disc edema. Oman J Ophthalmol [serial online] 2020 [cited 2020 Dec 2 ];13:176-177
Available from: https://www.ojoonline.org/text.asp?2020/13/3/176/299784


Full Text



A 45-year-old male presented with sudden onset diminished vision in both eyes for the last 2 weeks associated with occasional headache and dizziness for the last 2 months.

Medical history revealed an attack of hemorrhagic cerebrovascular accident 1 year back and was started on antihypertensive medication.

On examination, best-corrected visual acuity was 20/120 in both eyes. Intraocular pressure was 10 and 12 mm of Hg in the right and left eye, respectively. Anterior-segment evaluation was normal.

Dilated fundus examination revealed abnormal findings in both eyes as shown in [Figure 1]a and [Figure 1]b. Optical coherence tomography (OCT) findings are shown in [Figure 2]a and [Figure 2]b.{Figure 1}{Figure 2}

 Questions



What are the abnormal retinal findings as shown in [Figure 1]a and [Figure 1]b and [Figure 2]a and [Figure 2]b?What are the likely differential diagnoses?What are the baseline systemic investigations required?How to ascertain systemic risks associated with it from such fundus findings?

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 Answers for Clinical Quiz



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Fundus [Figure 1]a and [Figure 1]b shows bilateral disc edema with multiple peripapillary cotton wool spots, few scattered retinal hemorrhages, shallow subretinal fluid at posterior pole (exudative), and incomplete macular star formation in the right eye. [Figure 2]a and [Figure 2]b shows subretinal fluid and few intraretinal cystoid spacesMost likely diagnosis is malignant hypertensive retinopathy

Disc edema with macular star can also be seen in neuroretinitis.

Measurement of blood pressure is most important. Additional investigations should be done to find out the cause of malignant hypertension and target organ damage (e.g., electrocardiography, echocardiogram, imaging of brain, and renal artery Doppler/computed tomography angiogram).

If the patient is not hypertensive, infective and other causes of neuroretinitis need to be ruled out (e.g., tuberculosis, syphilis, lymes, cat scratch disease, leptospira, sarcoidosis, and viral etiology).

Hypertensive retinopathy changes along with disc edema have high systemic risks and strong association with mortality.[1]

Malignant hypertension (MHT) is the most severe form of hypertension (>180/110 mmHg) which can lead to acute ischemic target organ damage especially in eye, brain, kidney, and heart.[2] Retinopathy associated with MHT is characterized by optic disc swelling in addition to other retinal signs (hemorrhages, cotton wool spots, hard exudates, arteriolar changes). The systemic review of index case revealed severe hypertension 230/160 mm of Hg, concentric left ventricular hypertrophy on echocardiography, chronic kidney disease, and evidence of old hemorrhagic stroke on brain imaging, indicating target organ damage other than ocular involvement. Simple bedside fundus evaluation is a window to the systemic changes and reflects the more severe damages in other organs of the body.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004;351:2310-7.
2Rubin S, Cremer A, Boulestreau R, Rigothier C, Kuntz S, Gosse P. Malignant hypertension: Diagnosis, treatment and prognosis with experience from the Bordeaux cohort. J Hypertens 2019;37:316-24.