Abstract
A 23-day-old female child diagnosed as having systemic hypertensive emergency was referred for retinal screening. The fundus examination showed bilateral intraretinal haemorrhages and hard exudates especially at the macula. Venous looping was noted. The ocular features were suggestive of hypertensive retinopathy. Control of systemic hypertension was advised and was managed conservatively with close follow-up. Widefield fundus photography was done at presentation and follow-up to document the change in retinopathy with control of hypertension.
The haemorrhages and exudates resolved on follow-up but significant retinal pigment epithelium changes with beaten bronze appearance were noted at the area of previous oedema. Presence of hypertensive retinopathy in a neonate is rare and has long-term effects on visual development. This report describes the course of hypertensive retinopathy in a neonate.
Keywords: hypertension, retina, neonatal health
Background
Systemic hypertension in children and infants is diagnosed as systolic and/or diastolic blood pressure (BP) >95th centile for age and sex on three separate occasions.1 In the newborns, only systolic values are used. Measurement of BP in every neonate is a difficult task due to unavailability of a simple, safe and precise screening test. The reported incidence of neonatal hypertension varies from 0.2% in the healthy newborns to 2.6% in babies after admission in special care units and more than 40% in patients with chronic lung disease or bronchopulmonary dysplasia.2–4 A BP >30% above that expected for age constitutes hypertensive emergency.5
Ocular manifestations of systemic hypertension in adults are well known. However, hypertensive retinopathy is uncommon in children and extremely uncommon in neonates. We herein describe a neonate who presented to us with hypertensive retinopathy and its course of resolution.
Case presentation
A 23-day-old female child, born to a primigravida mother at gestational age of 36 weeks and a birth weight of 3.63 kg, was referred to our clinic 3 weeks at post-menstrual age 39 weeks for her ocular examination. She was delivered by normal vaginal delivery and had a difficult perinatal course. Right-sided shoulder dystocia was noted during labour and hence, assisted vaginal delivery with forceps was carried out. This led to right-sided Erb’s palsy. She had an Apgar score of 7/10 at 1 min and 9/10 at 5 min.
On post-natal day 6 in special newborn care unit, the child developed irritability and respiratory distress which required mechanical ventilation and intubation. She also developed seizure-like activity. On further systemic investigations she was diagnosed to have pulmonary haemorrhages, bilateral caudothalamic haemorrhage (on neurosonogram), patent foramen ovale with left to right shunt and pulmonary arterial hypertension. The systolic BP at this visit was recorded as 130 mm Hg. Renal doppler ultrasonography and ultrasonography of abdomen revealed normal study parameters. She was started on intravenous followed by oral anti-hypertensives and was referred for ocular examination. The last recorded BP was 71/35 mm Hg.
On Torch light examination, dazzle reflex was present. Anterior segment examination did not show any abnormality. Fundus examination of the right eye (figure 1A) showed a healthy disc with attenuated arterioles, dilated venules and venous looping in mid-periphery. Multiple intraretinal haemorrhages, mainly at the posterior pole, and extensive hard exudates were noted. Left eye (figure 1B) also had similar findings but lesser in severity. The peripheral retinal examination showed mature retina in both eyes. Both eyes showed grade 3 hypertensive retinopathy changes (as per adult classification). In view of controlled systemic status, observation was planned and parents were advised to continue treatment for systemic hypertension as per treating neonatologist. A close follow-up was advised to look for any further progression of retinopathy.
Figure 1.
(A, B) Right eye widefield fundus photograph showing multiple haemorrhages and hard exudates. Looping of veins was seen in mid-periphery (white circle). Left eye widefield fundus photograph shows macular and perivascular exudates (white arrow head).
Investigations
Renal doppler ultrasonography and ultrasonography of abdomen revealed normal study parameters. These were done to rule out renal causes of hypertension.
Differential diagnosis
A similar picture can be caused due to birth trauma especially when assisted delivery with forceps is carried out. However, such cases present with haemorrhages at multiple levels and minimal exudates.
Retinal vein occlusion presents with intraretinal haemorrhages, dilated and tortuous venules and macular oedema. Long-standing macular oedema can cause exudates. However, these cases are commonly unilateral. Bilateral acute changes with history of malignant hypertension in our case were consistent with hypertensive changes.
Treatment
In view of controlled systemic status, observation was planned and parents were advised to continue treatment for systemic hypertension as per treating neonatologist. A close follow-up was advised to look for any further progression of retinopathy.
Outcome and follow-up
On follow-up after 1 month, haemorrhages had completely resolved with presence of resolving hard exudates in both of her eyes (see figure 2A, B). Right eye showed subfoveal migration of hard exudates. At 6 months follow-up, the child was maintaining a central and steady fixation, without nystagmus. Objective refraction did not reveal any significant error. Fundus examination revealed complete resolution of hard exudates. However, retinal pigment epithelium changes with beaten bronze appearance was noted in right eye in area of previous exudates. The parents were advised for regular follow-up to assess visual development, screen for refractive error and development of strabismus.
Figure 2.
(A, B) Right eye widefield fundus photograph shows resolution of haemorrhages and migration of exudates. Left eye fundus photograph shows resolution of exudates.
Discussion
The incidence of hypertensive retinopathy in neonates is unknown and unlike in adults it does not appear to be related to duration of systemic hypertension. Largest study in literature discussing hypertensive retinopathy had 11 neonates showing clinical signs ranging from only arteriolar attenuation in most of the individuals to deeper blot haemorrhages and retinal exudates.6 Five infants showed complete clearing of the hypertensive changes 1–6 months after initial examination. Similar findings were noted in our case. It was notable to see foveal thinning after resolution of exudates.
Hypertensive retinopathy in adults after malignant hypertension commonly present with disc oedema, multiple intraretinal haemorrhages and cotton wool spots. It is important to note the absence of disc oedema and soft exudates in our case. The explanation to this remains uncertain.
Neonatal hypertensive retinopathy is an extremely rare finding. Although any ocular intervention was not carried out in our case, screening and establishing a diagnosis of retinal involvement carries long-term implications in prognostication. It is, thus, crucial to monitor visual development of the child in future. In a scenario, where universal eye screening is not an accepted norm, it is also important for the neonatologists and paediatricians to be aware of the entity for adequate referral.
Patient’s perspective.
As a mother, it was very difficult to see my child going through treatment in neonatal intensive care unit. When our neonatologist asked us to get an eye check-up done, I was very anxious. It was difficult for me to accept that the eyes were also affected because of the high blood pressure. But, I was relieved when our ophthalmologist said that no treatment would be required for the eyes. We had to continue the oral syrup (blood pressure medications). It also helped us to understand my baby’s condition of the serial photographs of eyes that were shown and explained to us.
Learning points.
Hypertension can cause retinopathy in neonates similar to adults.
The treatment of hypertensive retinopathy is observation with control of systemic hypertension.
Long-standing neurosensory detachment and exudates when resolved can cause foveal thinning and hence subnormal visual development.
Footnotes
Contributors: PG and KA contributed to literature search and drafting of the manuscript. KA was involved in active management of the patient.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Parental/guardian consent obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
- 1.Flynn JT. Neonatal hypertension: diagnosis and management. Pediatr Nephrol 2000;14:332–41. 10.1007/s004670050771 [DOI] [PubMed] [Google Scholar]
- 2.Adelman RD. Neonatal hypertension. Pediatr Clin North Am 1978;25:99–110. 10.1016/S0031-3955(16)33535-0 [DOI] [PubMed] [Google Scholar]
- 3.Friedman AL, Hustead VA. Hypertension in babies following discharge from a neonatal intensive care unit. A 3-year follow-up. Pediatr Nephrol 1987;1:30–4. 10.1007/BF00866881 [DOI] [PubMed] [Google Scholar]
- 4.Abman SH, Warady BA, Lum GM, et al. Systemic hypertension in infants with bronchopulmonary dysplasia. J Pediatr 1984;104:928–31. 10.1016/S0022-3476(84)80501-6 [DOI] [PubMed] [Google Scholar]
- 5.Feld GF, Waz WR. Pharmacologic therapy of hypertension : Feld GF, Hypertension in children. Boston: Butterworth-Heinemann, 1997: 133–78. [Google Scholar]
- 6.Skalina ME, Annable WL, Kliegman RM, et al. Hypertensive retinopathy in the newborn infant. J Pediatr 1983;103:781–6. 10.1016/S0022-3476(83)80485-5 [DOI] [PubMed] [Google Scholar]