A 62-year-old man with a history of poor medical follow-up comes to the office due to difficulty seeing. He has had blurry vision for the last 2 weeks. A day ago, he noticed a shadow develop suddenly across the visual field of his right eye. The patient has had no recent headaches, double vision, vertigo, light sensitivity, or nausea. On examination, pupils are equal and reactive to light. Visual field testing by confrontation reveals patchy loss of vision. A flame-shaped retinal hemorrhage in the right eye is noted on funduscopic examination, as shown in the image below. Which of the following is the most likely cause of his visual disturbance?

Question

A 62-year-old man with a history of poor medical follow-up comes to the office due to difficulty seeing.  He has had blurry vision for the last 2 weeks.  A day ago, he noticed a shadow develop suddenly across the visual field of his right eye.  The patient has had no recent headaches, double vision, vertigo, light sensitivity, or nausea.  On examination, pupils are equal and reactive to light.  Visual field testing by confrontation reveals patchy loss of vision.  A flame-shaped retinal hemorrhage in the right eye is noted on funduscopic examination, as shown in the image below.  Which of the following is the most likely cause of his visual disturbance?

Quizplus · Accepted Answer

11ec160b_39eb_0e6c_9249_af1e1dff35b7_MD0001_00 This patient has an acute retinal hemorrhage (arrow), most likely caused by severe, poorly controlled hypertension. Hypertensive retinal hemorrhage typically causes painless, unilateral visual disturbances, ranging from mild obscuration without loss of visual acuity to permanent blindness. Severe hypertension in retinal precapillary arterioles causes endothelial disruption, leakage of plasma into the arteriolar wall, and fibrinous necrosis. The necrotic vessels can then bleed into the nerve fiber layers, causing dot- and flame-shaped hemorrhages. Diagnosis of hypertensive retinal hemorrhage is usually confirmed by direct ophthalmoscopic evaluation. Other findings of hypertensive retinopathy include thickening of the arteriolar walls ("copper or silver wiring"), compression of the associated veins (arteriovenous nicking), and small, white foci of retinal ischemia (cotton-wool spots). (Choices A and D) Central retinal artery occlusion is most commonly due to atherosclerosis, cardioembolic disease, or vasculitis (eg, giant cell arteritis). It causes acute monocular vision loss. Examination can reveal a cherry red spot at the macula due to diffuse retinal ischemia, but hemorrhage is not typically seen. (Choices B and E) Smoking and hyperlipidemia can increase the risk of developing ischemic retinal and optic vascular disease; however, these are not associated with an increased risk of retinal hemorrhage. (Choice C) Closed-angle glaucoma is characterized by increased intraocular pressure from impaired aqueous humor drainage. It causes acute headache, eye pain, vision loss, and an afferent pupillary defect. Ophthalmoscopic examination reveals cupping of the optic disc without hemorrhage. (Choice G) Ocular migraine and migraine with visual aura can present with transient visual disturbances, with or without headache. Ophthalmoscopic examination is normal in patients with migraine. (Choice H) Thyroid eye disease (eg, Graves disease) can present with diplopia and proptosis; however, it is not associated with an increased risk of retinal hemorrhage. Educational objective: Severe hypertension in retinal precapillary arterioles causes endothelial disruption, leakage of plasma into the arteriolar wall, and fibrinous necrosis. The necrotic vessels can then bleed into the nerve fiber layer, which can be seen on examination as dot- or flame-shaped hemorrhages.

A 62-Year-Old Man with a History of Poor Medical Follow-Up