A 42-year-old man presented to the emergency department with bilateral blurred vision accompanied by severe occipital headache, nausea, and dizziness that had started 24 hours earlier. He had a known history of hypertension but admitted poor compliance with his antihypertensive medication and irregular medical follow-up. On admission, his blood pressure was 230/130 mmHg. He appeared uncomfortable and reported a rapid decline in visual acuity in both eyes.
Ophthalmologic examination revealed a best-corrected visual acuity of 20/40 in both eyes. Intraocular pressures were within normal limits bilaterally, and anterior segment examination was unremarkable. Dilated fundus examination demonstrated bilateral marked optic disc swelling with blurred and elevated disc margins consistent with hypertensive papillopathy. There were extensive peripapillary flame-shaped hemorrhages, multiple cotton-wool spots, and scattered Roth spots throughout the posterior pole. A macular star configuration formed by hard exudates was observed in both eyes. Additionally, several yellowish deep lesions suggestive of Elschnig spots, representing focal choroidal infarctions, were noted.
Macular optical coherence tomography revealed serous retinal detachment with subretinal fluid accumulation in the foveal region, along with nerve fiber layer edema. Hyperreflective intraretinal changes corresponding to ischemic damage were also present. No vitreoretinal interface abnormalities were detected.
Systemic evaluation demonstrated elevated serum creatinine levels and mild proteinuria, consistent with hypertensive nephropathy. Cardiac assessment revealed left ventricular hypertrophy on echocardiography. Neuroimaging excluded intracranial hemorrhage but showed findings compatible with hypertensive encephalopathy.
Based on the clinical and imaging findings, the patient was diagnosed with acute hypertensive crisis associated with bilateral grade IV hypertensive retinopathy and serous retinal detachment. He was admitted to the intensive care unit, and controlled intravenous antihypertensive therapy was initiated. Blood pressure was gradually reduced over 48 to 72 hours to avoid rapid perfusion changes that could compromise optic nerve or cerebral circulation.
This case illustrates the ocular manifestations of malignant hypertension, in which acute elevation of blood pressure leads to arteriolar damage, breakdown of the blood-retinal barrier, choroidal ischemia, optic disc edema, and serous retinal detachment. Prompt recognition and controlled systemic blood pressure management are essential to prevent permanent visual and systemic complications.
Acute hypertensive retinopathy represents an ophthalmic emergency and a marker of systemic end-organ damage. Fundus findings such as optic disc edema, flame-shaped hemorrhages, cotton-wool spots, macular star, and choroidal ischemic lesions reflect acute arteriolar injury and breakdown of the blood-retinal barrier. OCT may reveal serous retinal detachment and nerve fiber layer edema secondary to severe vascular compromise. Bilateral disc swelling in the context of markedly elevated blood pressure should always prompt urgent systemic evaluation. Careful but controlled blood pressure reduction is essential to preserve both visual function and vital organ perfusion.
Credit: Kemal Tekin, M.D., from Ulucanlar Eye Training and Research Hospital
Instagram accounts: @retina.academy and @dr.kemaltekin
