Hypertensive Retinopathy Presenting as Angle

Closure Glaucoma
Case Report
Dr. Divyalakshmi.K.S, Dr. Padmavathy.S, Dr.R. Ramakrishnan, Aravind Eye Hospital, Tirunelveli
Introduction
Hypertensive emergency condition is a condition
in which elevated blood pressure results in target
organ damage. In accelerated hypertension a recent
signifcant increase over baseline BP with target
organ damage is seen. And for diagnosis of Malignant
Hypertension papilledema must be present. Essential
hypertension accounts for 1% of all hypertensive
retinopathies, rest of the causes contributed by
secondary hypertension. Common causes include
renal artery stenosis, Pheochromocytoma, Aortic
coarctation, Hyperaldosteronism and Hyper-
thyroidism.
Ocular manifestations in hypertensive retinopathy
includes arteriolar changes, cotton wool spots,
retinal hemorrhages, lipid exudates, neuroretinal
edema, disc edema, choroidopathy, rarely massive
choroidal detachment / serous retinal detachment
and rarely angle closure glaucoma. Uveal effusion
with cilio-choroidal detachment leading to forward
rotation of lens - iris diaphragm has been postulated
as the mechanism of angle closure glaucoma in
hypertensive retinopathy.
Case report
A 32 year old young male presented with complaints
of acute painful progressive diminution of vision and
swelling of the left eye of 5 days associated with
projectile vomiting and headache. Systemic blood
pressure was 260/160 mmHg, BCVA in RE was
6/6 and LE 5/60. Intraocular pressure by Goldman
Applanation Tonometry was 20 mmHg in RE and
54 mmHg in LE. Anterior segment examination
showed congestion, intense chemosis, subconjunctival
hemorrhage, shallow anterior chamber (Fig.1 & 2)
and relative afferent pupillary defect in LE. Findings
in RE were within normal limits. Gonioscopy
showed open angles in RE and closed angles in LE.
Fundus evaluation through dilated RE and undilated
LE showed papilledema with a macular star (Fig.3).
Ultrasound B-scan of LE showed optic nerve head
elevation, RCS thickening and a shallow inferior RD.
His renal parameters were elevated and ultrasound
abdomen showed bilateral small sized kidneys with
type 1 medical renal disease and bilateral renal artery
stenosis. Neuroimaging which was done to rule
out intracranial space occupying lesion was within
normal limits.
Fig:1 & 2 Slit lamp view
Fig:3 Fundus image - right eye
17 AECS Illumination
Conclusion
Patient was treated with topical anti-glaucoma
medications including Alphagan P e/d TDS, Iobet
e/d BD and was immediately referred to a physician
for stabilization of systemic hypertension. Patient
was advised renal transplantation because of the
severity of renal disease.
As per JNC-7 patient had stage 2 hypertension
and stage 4 as per KEITH - WAGNER Staging. One
of the rare ocular manifestations of hypertensive
retinopathy is massive serous retinal detachment and
choroidal detachment and the possible mechanism
of angle closure glaucoma in such cases is Uveal
effusion with cilio-choroidal detachment leading
to forward rotation of lens - iris diaphragm. In
such cases although aqueous humor suppressants
and cycloplegics reduce the intraocular pressure,
resolution of all the fndings require adequate control
of systemic hypertension.
References
1. Arora et al: A case of renal hypertension presenting with angle closure glaucoma - Arch ophthal vol
109 June 1991.
2. Krohn et al: Uveal effusion and angle closure glaucoma in primary pulmonary HTN - Am J
Ophthalmol 2003.
3. Sheilds, Grant: Angle closure glaucoma in CRVO - AJO 1973 vol75.
4. Spontaneous massive hemorrhagic retinal or choroidal detachment -Ophthalmology Jan 1990, vol.97.
5. Topiramate toxicity and angle closure glaucoma - Am J Ophthal 2001.
Masquerade Syndrome due to Bronchogenic
Carcinoma
Case Report
Dr. Aditi Pujari, Aravind Eye Hospital, Madurai
A 45 year old male, painter by occupation presented
to us with chief complaints of pain and photophobia
in right eye for one and half months, which was
followed by sudden loss of vision in the same eye
after two days of onset of pain. He gave history of
chronic beedi smoking.
Patient was treated outside initially with some
eye drops and intramuscular injections. Then,
ophthalmologist outside had diagnosed right eye
exudative retinal detachment and had started
him on oral steroids, there was no symptomatic
improvement. The patient was referred to uvea clinic
as a case of non resolving uveitis.
On examination, visual acuity in right eye was
perception of light with accurate projection of rays,
and 20/20 in left eye. Intraocular pressure was 20
mm of Hg in right eye and 21 mm of Hg in left eye.
Anterior segment examination of right eye showed
circumcorneal congestion with clear cornea. Anterior
chamber was shallow with 1+cells and fare. Lens
was clear. Left eye anterior segment examination
was within normal limits. Right eye anterior
vitreous face showed 3+cells with multiple vitreous
membranes (Fig.1).
Right eye slit lamp photograph showing
shallow anterior chamber, anterior vitreous face
inflammation, vitreous membranes, and part of
exudative retinal detachment, seen inferiorly (Fig.1).
Fundus examination of right eye showed hazy
media with inferior exudative retinal detachment.
Near superotemporal arcade, a choroidal orangish
mass like lesion was seen with overlying pigmentary
changes. Left eye fundus was within normal limits.
(Fig 2)
Right eye slit lamp pho-
tograph showing shal-
low anterior chamber,
anterior vitreous face
infammation, vitreous
membranes, and part of
exudative retinal detach-
ment, seen inferiorly.
Right eye fundus photographs
Hematological investigations showed increased
leucocyte count (11,300/cu.mm) with neutrophilia
(78%). Peripheral smear was reported to have signs
of infammation or infection. ESR was 30 mm/hr.
RA f a c t o r , ANA,
Mantoux test and TPHA
was negative.
X- r a y c h e s t ,
showed a mass near
right hilum, thickening
of t he fi ssure, few
paratracheal and hilar
l ymph nodes wi t h
widened mediastinal
band. (Fig 3)
B-scan of right eye showed hyperechoeic mass
with extensive exudative retinal detachment. (Fig 4).
Fol l owi ng di fferent i al di agnoses were
considered: tuberculosis, choroidal melanoma,
secondaries metastatic lesion, posterior scleritis or
subretinal nocardiosis.
19 AECS Illumination
CT orbit showed a mass lesion and retinal
detachment in right eye extending in side to
side manner (typical of secondaries) and not in
anteroposterior manner
(typical of choroidal
melanoma). (Fig. 5)
CT chest showed a
bulky hilar mass with
hi l ar, par at r acheal
and supraclavicular
lymphnodes suggestive
o f b r o n c h o g e n i c
carcinoma. (Fig.6).
Based on above
fndings, our diagnosis
wa s Ma s q u e r a d e
s y n d r o m e d u e
t o b r o n c h o g e n i c
carcinoma presenting
with secondaries to
right eye, with choroidal
infltrate with exudative
retinal detachment.
Discussion
Uveitic Masquerade syndromes are a group of ocular
disorders that present as intraocular infammatory
processes but are in fact non-infammatory diseases.
In these patients, either intraocular infammation is
secondary to another initial disorder or the intraocular
cells and opacities are of non-infammatory origin
(e.g. pigments, blood or malignant cells).
Masquerade syndrome is caused by either
non malignant lesions (e.g., retinitis pigmentosa,
chronic peripheral retinal detachment, ocular
ischemic syndrome, intraocular foreign body, etc.)
or malignant lesions(like primary CNS lymphoma,
retinoblastoma, juvenile xanthogranuloma,
metastatic lesions, etc.). Neoplastic Masquerade
syndromes may account for 2%-3% of all patients
seen in tertiary uveitis referral clinics. Most common
intraocular malignancies in adults are metastatic
tumours. Carcinomas predominate as the primary
lesions that produce ocular metastases. Breast cancer
in women and lung cancer in men are the most
frequent, other common primary sites being the
kidney and gastrointestinal and genitourinary tracts.
Although breast cancer commonly metastasizes
to the eye, the primary tumor has been treated in
90% of cases by the time the ocular lesion is frst
noted. This is in contrast to ocular metastases from
renal and pulmonary malignancies, in which ocular
metastases are the frst presentation of disease in 80%
of cases. Choroidal metastasis is marked by severe
vitritis, serous retinal detachment, and occasionally
cystoids macular oedema. Lesions are often bilateral
and multifocal. Retinal metastasis is reported to be
very rare.
Bronchogenic carcinoma is common at around
55 years of age in Indian population. It is more
common in males, especially smokers. Common sites
for secondaries are adrenal glands (most common),
liver, intrapulmonary metastasis, and bones.
Choroidal metastasis is reported to be very rare.
Main treatment is in the form of systemic
chemotherapy and local radiotherapy for metastatic
lesions, including intraocular metastasis.
To conclude, in cases of non resolving uveitis,
differential diagnosis of Masquerade syndrome
should always be kept in mind even in systemically
asymptomatic patients and attention should be given
to investigations like chest X ray, which may give a
clue to the systemic involvement.
USG B Scan pictures of right eye
CT Orbit
CT Chest
Vol. XII, No.2, April - June 2012 20
References
1. Uveitic Masquerade syndromes (Ophthalmology 2001;108:386-399 Rothava et al).
2. Char DH. Clinical ocular oncology. Philadelphia: Lippincott-Raven, 1997.
3. Ferry AP, Font RL. Carcinoma metastatic to the eye and orbit: I. A clinicopathologic study of 227
cases. Arch Ophthalmol 1974;92:276286.
4. Shields JA, Shields CL, Kiratli H, et al. Metastatic tumors to the iris in 40 patients. Am J Ophthalmol
1995;119:422-430.
5. Shields CL, Shields JA, Gross NE, et al. Survey of 520 eyes with uveal metastases. Ophthalmology
1997;104:1265-1276.
6. AAO: Intraocular infammation and uveitis (Section 9) 2007-2008.