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Hypertensive Retinopathy Presenting as AngleClosure 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

signicant 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 hypertensiveretinopathies, 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


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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 theseverity 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 suppressantsand cycloplegics reduce the intraocular pressure,

resolution of all the ndings 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.


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Masquerade Syndrome due to BronchogenicCarcinoma

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 eyeexudative 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 are. 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 inammation or infection. ESR was 30 mm/hr.

R A f a c t o r , A N A ,

Mantoux test and TPHA

was negative.

X - r a y c h e s t ,

showed a mass near

right hilum, thickening

of the fissure, few

paratracheal and hilar

lymph nodes wi th

widened mediastinal

band. (Fig 3)B-scan of right eye showed hyperechoeic mass

with extensive exudative retinal detachment. (Fig 4).

Following differential diagnoses were

considered: tuberculosis, choroidal melanoma,

secondaries metastatic lesion, posterior scleritis or

subretinal nocardiosis.


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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 withhi lar , parat racheal

and supraclavicular

lymphnodes suggestive

o f b r o n c h o g e n i c

carcinoma. (Fig.6).

Based on above

ndings, our diagnosis

w a s M a 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

inltrate with exudative

retinal detachment.

Discussion

Uveitic Masquerade syndromes are a group of ocular

disorders that present as intraocular inammatory

processes but are in fact non-inammatory diseases.

In these patients, either intraocular inammation is

secondary to another initial disorder or the intraocular

cells and opacities are of non-inammatory 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 in90% of cases by the time the ocular lesion is rst

noted. This is in contrast to ocular metastases from

renal and pulmonary malignancies, in which ocular

metastases are the rst 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 systemicallyasymptomatic 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


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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.

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