Hypertensive Optic Disc Edema
- Swollen optic discs in the setting of acute systemic hypertension
- Signs of hypertensive retinopathy (and sometimes choroidopathy) are always present
- Caused by leakage of optic disc capillaries
- If vision loss is present, it is not attributable to an optic disc abnormality
- Other brain effects of acute systemic hypertension may be present
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Core features
- Acquired optic disc elevation in both eyes
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Tip: if optic disc edema is marked, do not blame malignant hypertension; look for an alternative cause
- Cotton wool spots, flame-shaped retinal hemorrhages
- Visual dysfunction, if present, is not caused by the optic disc abnormality
- Predisposing condition is a relatively acute rise in systemic blood pressure
- Fluorescein retinal angiography shows leakage at the optic disc and other abnormalities related to retinopathy and/or choroidopathy
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Possible accompanying features
- MRI may show signs of posterior reversible encephalopathy syndrome (PRES), brain hemorrhage, or ischemic stroke
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Tip: new vision loss is usually attributable to retinopathy, choroidopathy, or PRES
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Tip: intracranial pressure is not typically elevated
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Tip: when choroidopathy predominates, a misdiagnosis of Harada disease may occur
- Papilledema
- Harada disease
- Hypotensive optic neuropathy
- Optic neuritis
- Non-arteritic ischemic optic neuropathy
- Infiltrative optic neuropathy
- Optic disc edema in POEMS syndrome, perhaps caused by increased vascular permeability from high levels of vascular endothelial growth factor (VEGF)
- Look for the fundus signs of hypertensive retinopathy and choroidopathy
- Measure blood pressure
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Tip: an acute relative rise in blood pressure is more contributory than the absolute level of blood pressure
- Perform brain MRI to exclude PRES and other manifestations of acute systemic hypertension
- Lower blood pressure slowly to avoid the adverse effects of relative systemic hypotension
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Tip: if PRES is present, lowering of blood pressure is urgent to avoid ischemic stroke
- Optic disc edema, other fundus signs, and visual dysfunction should disappear within weeks unless infarction has occurred
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Trap: delay in diagnosis and lowering of blood pressure, or precipitous lowering of blood pressure, may lead to stroke in the visual cortex or optic disc and severe visual disability