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 Table of Contents  
PHOTO ESSAY
Year : 2021  |  Volume : 59  |  Issue : 2  |  Page : 214-215

Malignant hypertension – Optical coherence tomography grading and optical coherence tomography characteristics


Department of Medical Retina, Uvea and Neuro-Ophthalmology, Lotus Eye Hospital, Salem, Tamil Nadu, India

Date of Submission27-Oct-2020
Date of Acceptance22-Dec-2020
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. Priya Rasipuram Chandrasekaran
Department of Medical Retina, Uvea and Neuro-Ophthalmology, Lotus Eye Hospital, Salem, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_161_20

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  Abstract 


This photo essay describes the fundoscopic and optical coherence tomography (OCT) grading and characteristics of hypertensive retinopathy (HTR). A 34-year-old male presented with decreased vision of 20/40 N10 in both eyes following diagnosis of malignant hypertension. Fundus examination showed papilledema, intraretinal transudates, cotton wool spots, arteriovenous crossing changes, and superficial and deep hemorrhages with a partial macular star consistent with Grade 4 HTR. OCT macula revealed changes in the nerve fiber layer, outer nuclear layer, outer plexiform layer, and outer photoreceptor layer comprising inner segment/outer segment (OS) layer, external limiting membrane, and cone OS tips under the fovea with varied central subfoveal thickness. The fundoscopy grading of HTR was Keith–Wagener–Barker Grade 4 and that of OCT grading was Ahn Grade 3.

Keywords: Malignant hypertension, optical coherence tomography characteristics, optical coherence tomography grading


How to cite this article:
Chandrasekaran PR. Malignant hypertension – Optical coherence tomography grading and optical coherence tomography characteristics. TNOA J Ophthalmic Sci Res 2021;59:214-5

How to cite this URL:
Chandrasekaran PR. Malignant hypertension – Optical coherence tomography grading and optical coherence tomography characteristics. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Jul 27];59:214-5. Available from: https://www.tnoajosr.com/text.asp?2021/59/2/214/319274




  Introduction Top


A 34-year-old male presented with best-corrected visual acuity of 20/40 N10 in both eyes following diagnosis of malignant hypertension (MHT). Fundus examination revealed papilledema with cotton wool spot (CWS); partial macular star; superficial, deep, and subretinal hemorrhages; arteriovenous crossings; and macular edema. Fundus photo montage [Figure 1] using Zeiss Visucam 500 demonstrates the above findings. Cirrus HD optical coherence tomography (OCT) through the macula revealed a macular thickness of 688 μm and 732 μm nasally and central subfoveal thickness (CSFT) of 259 μm and 229 μm in both eyes, respectively. OCT through the edema showed irregular thickening and reflectivity of the nerve fiber layer (NFL), hyperreflective dots in the outer plexiform layer (OPL) and outer nuclear layer (ONL), intraretinal fluid in the ONL, and discontinuity of the outer photoreceptor layer (OPRL) [Figure 2]. OCT beneath the fovea demonstrated hyperreflectivity of OPL and ONL and disorganization and hyperreflective lines at OPRL [Figure 3]. Hypertensive retinopathy (HTR) grading was Grade 4 by Keith–Wagener–Barker fundoscopy and Grade 3 by Ahn OCT.
Figure 1: Fundus photo montage showing Grade 4 hypertensive retinopathy in both eyes with subretinal hemorrhage in the right eye

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Figure 2: Optical coherence tomography macula through the edema shows irregular thickening and hyperreflectivity of nerve fiber layer (yellow arrow), hyperreflective dots in the outer plexiform layer and outer nuclear layer (white arrow), intraretinal edema (pink arrow) mainly in the outer nuclear layer, and discontinuity of the outer photoreceptor layer (blue arrow) in both eyes, respectively

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Figure 3: Optical coherence tomography macula through the center of the macula shows hyperreflective dots in the outer plexiform layer and outer nuclear layer (pink arrow) and hyperreflectivity of the outer photoreceptor layer (yellow arrow) in both eyes, respectively

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  Discussion Top


Fundoscopic changes of Grade 4 HTR in our patient are in line with the findings of Keith et al. and Hayreh et al. demonstrating papilledema, periarteriolar and peripapillary changes leading to breakdown of retinal arteriole blood–retinal barrier, and intraretinal transudate.[1],[2] Arteriolar fibrinoid necrosis and NFL ischemia in MHT cause CWS which cause irregular thickening and hyper reflective NFL in OCT. Our patient fits into the OCT grading of Grade 3 HTR with papilledema and no sub retinal fluid (SRF) as per Ahn who correlated visual prognosis with SRF than fundoscopic findings.[3] CSFT appears to have been increased because of the associated disc edema and retinal edema. Changes in the OPRL in cases of malignant HTR in our patient are consistent with the findings of Liu et al. who had described its significance in predicting the visual outcome.[4]



Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: Their course and prognosis. Am J Med Sci Dec 1974;268:336-45.  Back to cited text no. 1
    
2.
Hayreh SS, Servais GE, Virdi PS. Fundus lesions in malignant hypertension IV. Focal intraretinal periarteriolar transudates. Ophthalmology 1986;93:60-73.  Back to cited text no. 2
    
3.
Ahn SJ, Woo SJ, Park KH. Retinal and choroidal changes with severe hypertension and their association with visual outcome. Invest Ophthalmol Vis Sci 2014;55:7775-85.  Back to cited text no. 3
    
4.
Liu XQ, Gao XR, Xu D, Xu C, Cao LN, Wang F. Restoration of outer segments of foveal photoreceptors after resolution of malignant hypertensive retinopathy. Int J Ophthalmol 2012;5:776-8.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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