Restoration of outer segments of foveal photoreceptors after resolution of malignant hypertensive retinopathy.

Dear Sir, I am Dr. Xiao-Qiang Liu, from the Department of Ophthalmology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China. I write to report a case of malignant hypertensive retinopathy demonstrated by spectral domain optical coherence tomography (SD-OCT). Malignant hypertension is defined as the most severe type of hypertension demonstrated by a sudden increase in blood pressure to very high levels (often over 180/120mmHg). It can cause damage to the small blood vessels in the eye and result in hypertensive retinopathy characterized by retinal arteriolar narrowing, retinal flame-shaped hemorrhages, and/or exudates or cotton wood spots, with or without papilloedema, retinal vein or artery occlusion, and optic nerve head swelling. Macular edema and exudative neurosensory detachments may develop as well [1-3]. Herein, we report a case of malignant hypertensive retinopathy demonstrated by spectral domain optical coherence tomography (SD-OCT). A 24-year-old man presented in ophthalmology department with an acute vision loss in both eyes. He denied any history of systemic or ocular disease other than refractive error. On examination, his best-corrected visual acuity (BCVA) was found to be reduced to 20/200 in both eyes. Anterior segment biomicroscopy, pupillary examination, and tonometry were unremarkable bilaterally. Ophthalmoscopy revealed bilateral mild optic disc edema, arteriolar narrowing, flame-shaped retinal hemorrhages, numerous cotton-wool exudates and serous retinal detachment of the macula(Figures 1A,B).SD-OCT (Cirrus, Carl Zeiss Meditec, Dublin, CA, USA) demonstrated bilateral macular edema and foveal serous neurosensory detachment (Figures 1C,D). Also of note is the disruption of the external limiting membrane (ELM), the inner segment/outer segment junction (IS/OS) and cone outer segment tips (COST) under the macula. Investigations related to the differential diagnosis of the fundus finding were soon performed. The patient's blood pressure was found to be 180/100mmHg. Laboratory tests revealed elevated levels of serum creatinine (6.06mg/dL) and blood urea nitrogen (45.12mg/dL). After consultation with a nephrologist, he was diagnosed with bilateral hypertensive retinopathy due to malignant hypertension. He was immediately admitted to the nephrology department for treatment of hypertension with oral nifedipine and arotinolol hydrochloride. After further examinations, an additional diagnosis of chronic renal insufficiency was made, although its exact etiology was unknown. The patient refused dialysis treatment and his hypertension gradually came under control by antihypertensive medication. Two weeks later, his blood pressure was reduced to 130/80mmHg, and his BSCV improved to 20/67 in both eyes. The cotton-wool exudates and retinal hemorrhages in both eyes had largely resolved (Figures 2A,B). SD-OCT demonstrated normal foveal contour and almost complete resolution of the subretinal fluid in both eyes except a mild foveal neurosensory detachment in the left eye. There were numerous areas of high intensity signal intraretinally in both eyes, corresponding to areas of lipid exudation. A large defect of ELM line, IS/OS line and COST line under the macula was also showed in both eyes (Figures 2C,D). Two months later, the patient's blood pressure remained under good control medically and his BSCV had returned to 20/20 in the both eyes. Except a little intraretinal hemorrhages remained, cotton-wool exudates and hard exudates had completely resolved in both eyes (Figures 3A,B). SD-OCT showed complete resolution of the subretinal fluid and almost complete restoration of the ELM line and IS/OS line in both eyes, while the COST line was still interrupted(Figures 3C,D). SD-OCT of malignant hypertensive retinopathy