This 44YO male patient presented with a 2-week history of bilateral vision loss. He denied any past medical history.
Vision was 20/150 OD and 20/50 OS. Optos imaging shows bilateral optic nerve swelling, flame-shaped retinal hemorrhages, and macular lipid.
Swept-source OCT shows bilateral subretinal fluid extending from the nerve into the macular centers. A plaque of outer retinal hyperreflective lipid is noted in the nasal right macula, with hyperreflective dots of suspended lipid within the outer retinal edema in his left eye.
Blood pressure was 242/136. He was immediately sent to the emergency room for treatment of his malignant hypertension.
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 macular fluid originates from the optic nerve, macular thickening is always worse nasally (as in our case) and is an important clinical clue for this diagnosis.
