Atlas of Ophthalmology

Bilateral Optic Disk Edema and Macular Star Figure in Malignant Arterial Hypertension (Colour Photography Posterior Pole, OCT)

Hypertensive Retinopathy
Patient: 21 years of age, male, visual acuity 0.4 at OD and 0.3 at OS. IOP 16/17 mmHg, pupils normally reactive to light and isocoric, no relative afferent pupillary defect, extraocular motility examination normal, no nystagmus. General Medical History: headache, systemic blood pressure measured 200/120 mmHg. Ocular Medical History: decrease of vision since two weeks, blurry vision of increasing severity at night. Main Complaint: blurry vision. Purpose: to present optic nerve head edema in acute arterial hypertension. Methods: Colour Photography Posterior Segment, Optical Coherence Tomography OCT. Findings: Colour Photography Posterior Segment: bilateral grade IV optic disk edema with surrounding peripapillary flame-shaped hemorrhages, macular star figure, reduced retinal arterial caliber, cotton wool patches, choroidal abnormalities. OCT: edema of all retinal layers, intraretinal fluid temporal to the disc, subretinal fluid temporal to the disc. OCT RNFL circle scans: grade IV papilledema, edema of all retinal layers, intraretinal fluid temporal and nasal to the disc, subretinal fluid temporal and nasal to the disc. Discussion: Patients with chronic essential hypertension may have only mild changes in the size of retinal vessels. Patients with acute arterial hypertension can develop optic disk swelling with retinal hemorrhages and cotton wool spots. Optic disk edema (grade IV hypertensive retinopathy) is a marker of malignant hypertension. 1-2 Hypertensive optic neuropathy and optic disk edema leads to hypoxia at the optic nerve head producing proximal axoplasmic flow stasis and secondary axonal swelling. Thus optic disk swelling is caused by obstruction of axonal transport at the lamina cribrosa. Etiologies of optic disk edema include also elevated intracranial pressure, inflammation, infection, demyelination, ischemia, compression, infiltration, toxic insults, metabolic deficiency, and mitochondrial disorders. Presence of a macular star figure in combination of optic disk swelling suggests inflammation, infection, increased ICP, or ischemia. Literature: (1) Lee AG, Beaver HA. Acute bilateral optic disk edema with a macular star figure in a 12-year-old girl. Surv Ophthalmol. 2002 Jan-Feb;47(1):42-9. (2) S Kishi, M.O Tso, S.S Hayreh. Fundus lesions in malignant hypertension. II. A pathologic study of experimental hypertensive optic neuropathy. Arch Ophthalmol, 103 (1985), pp. 1198–1206

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