This previously healthy 40YO female presented with 2 months of painless bilateral vision loss. She had occasional headaches, which she self-medicated with painkillers. Vision was counting fingers OD and 20/120 OS.
Color photography in her right eye shows a mildly swollen nerve, extensive hemorrhages in the nerve fiber layer, nerve fiber layer infarcts (cotton-wool spots), and a macular lipid star. OCT scanning shows outer retinal fluid with hyperreflective lipid flecks and foveal subretinal fluid. Similar findings are present in her left eye.
Her blood pressure in our office was 166/122 mmHg. She was immediately referred for emergent medical care.
Learning Points:
Malignant hypertension, defined as blood pressure above 180 systolic and/or 120 diastolic, is a life-threatening medical emergency. Eye doctors are in a unique position to often diagnose this condition. Patients will often present with bilateral optic nerve swelling, flame-shaped retinal hemorrhages, and, with more chronic disease, lipid precipitates in the nasal macular outer plexiform layer. Since the macular fluid emanates from the optic nerve, the macular lipid and thickening are virtually always worse nasally and are an important clinical clue for this diagnosis.
