Images in Clinical Medicine
Bilateral Blurred Vision in a “Healthy” Adult
N Engl J Med 2010; 363:964September 2, 2010
- Article
A 40-year-old man presented with a 5-week history of headaches and blurred vision in both eyes, with no other medical history. He reported having no chest pain or shortness of breath. A physical examination was notable for a blood pressure of 210/130, and the visual acuity was 20/200 in both eyes. Fundus examination revealed optic-disk hyperemia and blurring (long arrow), retinal hemorrhage (short arrow), a macular “star” with lipid deposits (arrowhead), and venous congestion, in both the right eye (Panel A) and the left eye (Panel B). The patient was admitted to the hospital and given urgent care. Urinalysis revealed polyuria and low urinary osmolality. Patients with malignant hypertension, such as our patient, have a diastolic blood pressure of 130 mm Hg or higher in association with ocular pathologic features. These ocular findings can also be caused by blood dyscrasias, systemic lupus erythematosus, neuroretinitis, sarcoidosis, or eclampsia. Changes in the retina may result in permanent loss of vision. This patient was given atenolol, amlodipine, and enalapril for the high blood pressure. One month later, the fundus showed clinically significant improvement (see the Supplementary Appendix, available with the full text of this article at NEJM.org). Two months after presentation, the patient's blood pressure was normal (128/80 mm Hg), and his visual acuity had improved to 20/60.
Jaime Levy, M.D.
Tova Lifshitz, M.D.
Soroka University Medical Center, Beer-Sheva, Israel
ljaime@bgu.ac. il
