Malignant Hypertension With Bilateral Optic Nerve Edema

This is a case of malignant hypertension and severe hypertensive retinopathy. A 30-year-old woman with headache and vision loss in the left eye was found to have a markedly elevated blood pressure of 205/100. CT head without contrast showed acute hemorrhage in the right temporal-occipital junction and occipital horn of the lateral ventricle (Figure 1). Photographs of the posterior pole of the retina in both eyes two days following presentation showed retinal arterial narrowing with focal irregularities, retinal hemorrhages, exudates and cotton wool spots in both eyes (Figure 2). Optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) showed increased RNFL thickness in both eyes, consistent with bilateral optic nerve edema (Figure 3). OCT macula showed an exudative retinal detachment in the right eye (Figure 4). Humphrey visual fields (24-2 SITA Fast) showed a left homonymous hemianopia as well as generalized depression in both eyes (Figure 5). She was diagnosed with a left homonymous hemianopia due to a right occipital lobe hemorrhage and malignant hypertensive retinopathy in both eyes. Figure 1. Color photographs of both eyes, centered on the optic nerves, showed bilateral optic nerve edema, cotton wool spots, hard exudates, flame-shaped retinal hemorrhages and arteriovenous (AV) nicking. Figure 2. CT Head without contrast showed an acute hemorrhage in the right temporal occipital junction and occipital horn of the lateral ventricle (Figure 2). CT angiogram and cerebral angiogram were normal.Figure 3. Optical Coherence Tomography (OCT) of the retinal nerve fiber layer (RNFL) shows increased RNFL thickness in both eyes, consistent with bilateral optic nerve edema. Figure 4. Spectralis optical coherence tomography (OCT) of the macula showed bilateral optic nerve edema, macular hard exudates (both eyes) and subretinal fluid (right eye). Figure 5. Humphrey visual fields (24-2 SITA Fast) showed a complete left homonymous hemianopia (red outline) due to the right temporal-occipital hemorrhage, as well as non-specific changes in both eyes due to hypertensive retinopathy affecting both eyes.