Bilateral exudative retinal detachment and choroidopathy as the presenting signs of malignant hypertension

Description

A 24-year-old man presented with sudden-onset bilateral loss of vision with persistent headaches for 3 days. His visual acuity (VA) in the right eye was 20/1200 and in the left eye was finger counting close to face. Both pupils were equally reactive and anterior segment examination was normal bilaterally. Dilated fundus evaluation revealed bilateral serous retinal detachment with macular involvement (figure 1A, B). Multiple white patches were noted lying deep to the retina in both eyes (figure 1A, arrow) consistent with Elschnig spots.¹ His blood pressure (BP) was found to be 246/143 mm Hg and he was referred to emergency medicine for further management. A diagnosis of bilateral exudative retinal detachment with hypertensive choroidopathy in malignant hypertension was made.

Figure 1.

Widefield colour fundus photographs of a patient with malignant hypertension showing exudative retinal detachment in the right eye (A) with elschnig spots (yellow arrow), (A) and left eye (B). Three weeks after adequate blood pressure control, the retinal detachment resolved in the right eye (C) and the left eye (D) with few residual retinal haemorrhages (black arrow) (D).

The patient was admitted for management of hypertensive emergency. He was found to have acute renal failure requiring emergent dialysis. The aetiology of his renal failure was unclear at the time of discharge and he was started on outpatient intermittent haemodialysis. Three weeks after blood control was achieved, his VA improved to 20/80 and 20/63 in the right and left eye, respectively. The retinal detachments in both eyes resolved (figure 1C, D) with few residual haemorrhages (figure 1D, arrow).

Severe and acute elevation in BP can cause hypertensive choroidopathy as choroidal vessels are more prone to damage in such conditions. These vessels do not have a well-developed autoregulation mechanism, presence of adrenergic receptors and a short course with minimal branching.^{2 3} This causes downstream transmission of acute elevation in BP and causes fibrinoid necrosis of choroidal arterioles and occlusion of areas of choriocapillaris.⁴ Necrosis of the overlying retinal pigment epithelium causes pale yellow white lesions called Elschnig spots.¹ This can lead to breakdown of the outer blood–retinal barrier and rarely can cause massive exudative retinal detachment.^{5 6} Another possible differential diagnosis for a young patient with complaints of headache and bilateral serous retinal detachments can be Vogt-Koyanagi-Harada disease. Although, these patients also have accompanying signs of ocular inflammation involving the anterior and/or the posterior segment and often other integumentary and neurological signs and symptoms.⁷ Also, cases of hypertensive choroidopathy due to choroidal ischaemia and associated exudative retinal detachment with minimal to no abnormalities in retinal circulation have been described in association with pre-eclampsia and eclampsia, renal failure, systemic lupus erythematosus, disseminated intravascular coagulation, thrombotic thrombocytopenic purpura and Castleman’s disease.^{3 6 8} Most of the cases of acute hypertenisive choroidopathy with serous retinal detachments resolve with control of BP. Hypertensive choroidopathy can present independent of retinopathy and this case demonstrates an extreme example of ocular manifestation of a life threatening hypertensive emergency.

Patient’s perspective.

I was unaware of my underlying issue of uncontrolled hypertension until I got myself evaluated for my complaint of loss of vision by an ophthalmologist.

Learning points.

• Patients with malignant hypertension may present first to an ophthalmologist with vision loss being their predominant complaint.

• Acute massive elevation of blood pressure can cause hypertensive choroidopathy and exudative retinal detachment without underlying retinopathy changes.