EyeSpyOphthalmic Education

Case 05 - Retina and vascular pathology

Morning Headaches and Abnormal Fundus

55-year-old man - Morning occipital headaches worsening x months - Bilateral symmetric fundus

Illustrated eye for pathology case review
Case 05Hypertensive Retinopathy

Clinical Presentation

A 55-year-old man has complained of morning occipital headaches for several months, recently becoming more frequent and severe. The fundus appearance was similar in both eyes.

Learner Questions

  1. What additional history should you obtain?
  2. Describe the ophthalmoscopic findings.
  3. What are the histopathologic correlates of these findings?
  4. Outline your diagnosis and plan for management.

Answer Framework

History

Duration of HTN, BP compliance/medications, renal disease, DM, symptoms of HTN emergency (AMS, chest pain, SOB, focal neuro deficits), visual symptoms (transient obscurations = papilledema), tobacco/alcohol, family history of cardiovascular disease.

Histopathology

Flame hemorrhages = NFL extravasation (linear, parallel to nerve fibers). Cotton-wool spots = axoplasmic debris (cytoid bodies) from focal ischemia - NOT true exudate, no lipid. AV nicking = thickened arteriolar wall mechanically compresses venule at shared adventitial crossing. Macular star = lipid in Henle's layer.

Findings

Bilateral disc edema (blurred margins), flame-shaped hemorrhages (NFL), cotton-wool spots (NFL infarcts), AV nicking, copper/silver wiring, macular star (hard exudates in Henle's fiber layer). = Keith-Wagener-Barker Grade III-IV hypertensive retinopathy.

Management

Hypertensive emergency: ICU, IV antihypertensives (labetalol/nicardipine/clevidipine), reduce MAP <=25% in first hour. Renal panel, ECG, CXR, brain MRI if neuro symptoms. Secondary HTN workup: renal artery stenosis, pheochromocytoma, Cushing's, primary hyperaldosteronism.

Teaching Pearl

KWB Grade III/IV = end-organ damage - treat the patient, not just the eyes. Morning headaches + bilateral disc edema = hypertensive emergency until proven otherwise. KWB: I = AV narrowing; II = AV crossing changes; III = hemorrhages + exudates + CWS; IV = III + disc edema. These patients often need ICU admission.

Original answer transcript 
History Histopathology
Duration of HTN, BP compliance/medications, renal disease, DM, symptoms of HTN Flame hemorrhages = NFL extravasation (linear, parallel to nerve fibers). Cotton-wool spots
emergency (AMS, chest pain, SOB, focal neuro deficits), visual symptoms (transient = axoplasmic debris (cytoid bodies) from focal ischemia - NOT true exudate, no lipid. AV
obscurations = papilledema), tobacco/alcohol, family history of cardiovascular disease. nicking = thickened arteriolar wall mechanically compresses venule at shared adventitial
crossing. Macular star = lipid in Henle's layer.
Findings Management
Bilateral disc edema (blurred margins), flame-shaped hemorrhages (NFL), cotton-wool Hypertensive emergency: ICU, IV antihypertensives (labetalol/nicardipine/clevidipine),
spots (NFL infarcts), AV nicking, copper/silver wiring, macular star (hard exudates in Henle's reduce MAP <=25% in first hour. Renal panel, ECG, CXR, brain MRI if neuro symptoms.
fiber layer). = Keith-Wagener-Barker Grade III-IV hypertensive retinopathy. Secondary HTN workup: renal artery stenosis, pheochromocytoma, Cushing's, primary
hyperaldosteronism.
TEACHING PEARL
KWB Grade III/IV = end-organ damage - treat the patient, not just the eyes. Morning headaches + bilateral disc edema = hypertensive emergency until proven otherwise.
KWB: I = AV narrowing; II = AV crossing changes; III = hemorrhages + exudates + CWS; IV = III + disc edema. These patients often need ICU admission.