The present case report appears in JAMA.
A woman in her mid-20s presented with subacute bilateral vision loss that was worse in the left eye. Her medical history was remarkable for type 1 diabetes diagnosed at 16 years of age and proliferative diabetic retinopathy in both eyes that had been treated with panretinal photocoagulation 7 years earlier.
She had undergone pars plana vitrectomy with endolaser to treat a tractional retinal detachment in her right eye 2 years before this presentation. She also had a history of hypertension and chronic kidney disease, and she was 15 weeks into pregnancy.
Visual acuity was 20/50 OD and 20/100 OS. Intraocular pressure was normal bilaterally, and no relative afferent pupillary defect was detected. Findings of an anterior segment examination were normal. The patient was in no apparent distress and denied any headache, chest pain, or focal weakness.
The patient was found to have hypertension, with a blood pressure of 195/110 mm Hg. This patient had mild optic nerve edema despite high systemic blood pressure and substantial macular edema. This less-pronounced optic nerve edema likely was attributable to optic nerve atrophy at baseline. Severe hypertension resulting in acute retinopathy and optic nerve head edema is considered a hypertensive emergency because of its association with end-organ damage, namely, damage to the retina and optic nerve.
This case serves as a reminder that, although the differential diagnosis for optic nerve head edema is broad, immediately assessing the patient’s blood pressure to evaluate for hypertensive emergency in the eye clinic may be critical, because this treatable condition could lead to substantial morbidity or mortality if diagnosis is delayed.
Final Diagnosis: Malignant hypertension with papillopathy