Unilateral hypertensive choroidopathy as a sole manifestation in malignant hypertension: optical coherence tomography angiography findings-case report

Optical Coherence Tomography Angiography Findings Associated With Accelerated Hypertension

Introduction Accelerated hypertension, that is a systolic blood pressure greater than 180 mmHg and a diastolic blood pressure greater than 120 mmHg is often accompanied by fundoscopic signs with the potential of systemic and visual morbidity. We report on the clinical and optical coherence tomography angiography (OCTA) findings in a cohort of hypertensive patients with accelerated hypertension. Methods Patients, presenting to the emergency room/intensive care unit, who met the clinical definition of accelerated hypertension (a blood pressure >180/120 mmHg,), were triaged to the intensive care unit. Following blood pressure reduction via pharmacological methods, a standard panel of hematological tests, cardiac evaluation tests, and the necessary systemic imaging was performed. They underwent a bedside dilated fundus examination with subsequent fundus photography/OCTA using a Topcon DRI OCT plus (Topcon Corporation, Tokyo, Japan). The records of these patients were evaluated. Results We analyzed the records of 16 patients (12 males (75%), and four females (25%)) with ages ranging from 16 to 75 years (mean 47.6 years). Eleven patients consented to a detailed evaluation. These included nine males (81.8%) and two females (18.1%) with ages ranging from 16 to 63 years (mean 46.3 years). Comorbidities included pre-existing hypertension (nine patients, 81.8%), chronic kidney disease (three patients, 27.2%), and diabetes mellitus type 2 (two patients, 18.1%). Clinical findings in these 22 eyes included arteriolar changes consistent with Keith Wagener Barker (KWB) grade 1 (two eyes, 9.0%), grade 2 (10 eyes, 45.4%), grade 3 (eight eyes, 36.3%), and grade 4 (two eyes, 9.0%). OCTA findings included capillary nonperfusion in the superficial capillary plexus in the areas of retinal opacification (seven eyes, 31.8%). Conclusion OCTA studies of the macular, as well as the entire posterior pole vasculature, may help to detect retinal microangiopathy, permit accurate grading, and subsequently develop a model that permits the quantification of systemic and ocular risk in these patients.

Atypical presentation of malignant hypertension

A woman in her 30s presented with complaints of sudden onset of defective vision in the right eye for 2 days, with history of headache for a month. On examination, best corrected visual acuity was 20/40 in the right eye and 20/20 in the left eye. Anterior segment examination was normal. Fundus examination of both the eyes showed generalised arteriolar attenuation with diffuse, hyperaemic disc oedema and serous retinal detachment at macula in the right eye. Her blood pressure (BP) was 230/140 mm Hg. Other systemic evaluation was unremarkable. In the review visit, patient's BP reduced to 140/100 mm Hg, and visual acuity in the right eye improved to 20/20. Fundus in the right eye showed resolving disc oedema with macular star formation, and the left eye had developed soft exudates. This seemed to confirm the diagnosis of the disc oedema being caused by hypertension and a highly asymmetrical presentation of hypertensive retinopathy.