Malignant Hypertension

Fundus photograph and red free image (right eye)

There are intraretinal haemorrhages and hard exudates present in the inferior macula in the inferior vascular arcades and flame-shaped haemorrhages superior and inferior to the disc. Numerous discrete hypopigmentary changes are noted in all quadrants consistent with Elschnig spots secondary to hypertensive choroidopathy. The optic disc margins appear indistinct indicating mild optic disc oedema. Arterial attenuation and arteriovenous nipping are present.

Fundis photograph and red-free image (left eye)

The left optic disc shows more obvious signs of swelling. There are prominent hard exudates surrounding the inferior half of the disc including a partial macular star temporal to the disc. Other features include numerous Elschnig spots, arterial attenuation and flame-shaped haemorrhages are inferior to the optic disc.

Optomap and green separation images (right and left eye)

These images demonstrate the extent of the hard exudates around the left optic disc. There are dark artifacts, caused by posterior sub-capsular cataracts, obscuring some of the retinal features in each eye.

Spectralis OCT line scans (right eye)

OCT line scans show a thickening of the peripapillary retinal nerve fibre layers (RNFL) and elevation of the optic disc. Nasal to the disc, a v-contour is evident, a finding that supports the diagnosis of papilloedema (please review the chapter on Papilloedema in this resource for more information - link available at the bottom of this page).

Spectralis OCT line scans (left eye)

OCT shows a thickened peripapillary RNFL, elevation of the optic nerve head and numerous hard exudates with associated intraretinal cystoid oedema adjacent to the disc.

Cirrus RNFL analysis

The RNFL thickness map shows "rainbow rings" typical of papilloedema, more notable in the left eye. TSNIT curve shows a significant increase in RNFL thickness inferiorly in the left eye (compared with both normative data and the right eye). These findings support a diagnosis of papilloedema (please see the relevant chapter in this resource for more information).

Fundus photograph and red-free image (right eye)

Retinal photos show the disc margins to be indistinct with Paton folds visible temporal to the disc (magnified photo also provided). There is no visible cup . AV crossing changes are visible at the vascular arcades and Salus's sign is present at the superior arcade. Significant arteriolar narrowing is present.

Fundus photograp and red-free image (left eye)

Retinal photos show slightly indistinct disc margins. AV nipping is evident in the superior and inferior vascular arcades and there is significant arteriolar narrowing.

Red-free image showing Paton folds

Paton folds are a series of lines that run concentric with the optic disc and are a sign of papilloedema. They are caused by the stress induced on the optic nerve head by high intracranial pressure.

Stereoscopic view of right optic disc

View image with a stereo viewer or 15 prism dioptres base out.

A stereoscopic view of the optic nerve allows appreciation of its elevated appearance.

Stereoscopic view of left optic disc

View image with a stereo viewer or 15 prism dioptres base out.

A stereoscopic view of the optic nerve also reveals elevation, but not as prominent as in the right eye.

Spectralis OCT line scans (right eye)

OCT shows subtle hyper-reflectivity corresponding to the Paton folds within the RNFL layer temporal to the disc. The disc appears elevated with no optic cup.

Spectralis OCT line scans (left eye)

The optic disc appears mildly elevated with a small cup.

Cirrus RNFL Analysis

RNFL thickness maps show subtle "rainbow rings" and the TSNIT curve indicates likely increased RNFL thickness in both eyes. These findings, in combination with the clinical signs of Paton's folds, hypertensive retinopathy and indistinct disc margins, indicate likely papilloedema. In the context of severe hypertension, a diagnosis of malignant hypertension is most likely. This patient was referred promptly to the emergency department.