This 57YO male presented with unilateral optic nerve swelling in his left eye and a few faint nasal macular retinal hemorrhages in his right eye. Vision was 20/40 OD and 20/25 OS.
OCT was normal OD and thickened in the nasal outer nuclear layer OS. Visual fields were normal OD and inferiorly depressed, especially inferonasally, OS.
Blood pressure was 190/110, and he was immediately referred to the emergency room.
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. However, rarely, the ocular findings may be asymmetric or even unilateral.
Since the macular fluid emanates from the optic nerve, the macular thickening is always worse nasally (as in our case), and is an important clinical clue for this diagnosis.
Our patient may also have had an isolated anterior ischemic optic neuropathy in his left eye and mild hypertensive retinopathy in his right eye. The partial altitudinal deffect is more common with this diagnosis than hypertension.
