|
 |
| 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
| Date of Submission | 15-Oct-2018 |
| Date of Decision | 09-Dec-2018 |
| Date of Acceptance | 25-Nov-2019 |
| Date of Web Publication | 2-Nov-2020 |
Correspondence Address:
Dr. Ramanuj Samanta
Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.OJO_222_2018
How to cite this article:
Samanta R, Puthalath AS, Saraswat N, Agrawal A. 3D: Decreased vision, dizziness, and disc edema. Oman J Ophthalmol 2020;13:176-7 |
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: (a and b) Fundus photograph of the right and left eye, respectively
Click here to view |
 | Figure 2: (a and b) Optical coherence tomography picture of the right and left eye, respectively
Click here to view |
 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?
 View Answer
| Answers for Clinical Quiz | | |
l - 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 spaces
- Most 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 sponsorshipNil. Conflicts of interestThere are no conflicts of interest.
| References | | |
| 1. | Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004;351:2310-7.  |
| 2. | Rubin 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. |
[Figure 1], [Figure 2]
|
