Proliferative retinopathy is a common end point for many retinal vascular diseases but has not been previously reported as an acute presentation of uncontrolled malignant hypertension. We present a case of severe uncontrolled hypertension in a man who presented with bilateral retinal ischemia, neovascularization, proliferative retinopathy, and tractional retinal detachment.
A man in his middle to late 40s presented to the emergency department with worsening vision bilaterally for the prior 8 months with a more recent deterioration in the right eye. His visual acuity was counting fingers OD and hand motion OS. His blood pressure was 270/160 mm Hg. Anterior segment examination findings were unremarkable in both eyes. Ophthalmoscopy revealed dense vitreous hemorrhage in the right eye and moderate vitreous hemorrhage, fibrovascular proliferation along the superior and inferior arcade that resulted in a tractional retinal detachment of the macula, and multiple areas of neovascularization in the left eye (Figure, A). Wide-field angiography revealed poor filling of the choroid, arterioles, poor arteriolar-venous transits, significant capillary dropout of the retina, and leakage in the areas of neovascularization (Figure, B and C). He reported not seeing a physician in more than 10 years. He denied any pertinent medical history and was not taking any medications. His family history was notable for hypertension. An extensive inpatient investigation did not reveal any secondary causes for his elevated blood pressure or alternative explanations for the proliferative retinopathy. Studies with normal results included renal ultrasonography, urine toxicology, and laboratory values for renin and aldosterone, antineutrophil cytoplasmic antibody, angiotensin-converting enzyme, and hemoglobin A1c measurement (5.6% [to report to proportion of total hemoglobin, multiply by 0.01]). In addition, all blood glucose finger stick test results were normal.
Stryjewski TP, Papakostas TD, Vavvas D. Proliferative Hypertensive Retinopathy. JAMA Ophthalmol. 2016;134(3):345-346. doi:10.1001/jamaophthalmol.2015.5583