- Email: [email protected]
Hypertensive choroidopathy, retinopathy and optic neuropathy in renal transplantation failure
a r c h s o c e s p o f t a l m o l . 2 0 1 9;9 4(1 1):551–555
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Hypertensive choroidopathy, retinopathy and optic neuropathy in renal transplantation failure夽 J.L. Sánchez-Vicente a , F. López-Herrero a , A.C. Martínez-Borrego a,∗ , B. Lechón-Caballero a , A. Moruno-Rodríguez a , F.E. Molina-Socola b a b
Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, Spain Oftalmología, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
A 32 year-old man who presented with severe elevation of blood pressure after failure of
Received 18 February 2019
kidney transplant. The patient had multiple serous retinal detachments, venous dilation,
Accepted 9 July 2019
arteriolar narrowing, retinal haemorrhages, as well as optic disc oedema.
Available online 8 October 2019
Due to the impossibility of performing a fluorescein angiography, an angiotomography and en-face optical coherence tomography images were used to identify the vascular alterations
Keywords: Hypertensive retinopathy Hypertensive choroidopathy Hypertensive optic neuropathy
in the retina, choroid, and choriocapillaris. Angiotomography and en face-optical coherence tomography mode images are very usefulin cases where it is not possible to perform fluorescein angiography. ˜ ˜ S.L.U. All rights de Oftalmolog´ıa. Published by Elsevier Espana, © 2019 Sociedad Espanola reserved.
Hypertensive emergency Retinal serous detachment Renal failure Angiotomography En face-optical coherence tomography
Coroidopatía, retinopatía y neuropatía óptica hipertensiva en un paciente con fracaso de trasplante renal r e s u m e n Palabras clave:
˜ Varón de 32 anos que presenta una elevación grave de la tensión arterial con cifras de
Retinopatía hipertensiva
200/140 mmHg tras fracaso de trasplante renal. Se observaron múltiples desprendimientos
Coroidopatía hipertensiva
serosos retinianos, dilatación venosa y atenuación de las arteriolas, hemorragias retinianas
Neuropatía óptica hipertensiva
y edema del disco óptico.
夽 Please cite this article as: Díez-Montero C, Fernández-Pérez GC, Galindo-Ferreiro A. Fístula orbitaria supratroclear secundaria a la realización de un bloqueo para anestesia en una cirugía de catarata. Arch Soc Esp Oftalmol. 2019;94:561–565. ∗ Corresponding author. E-mail address: [email protected] (A.C. Martínez-Borrego). ˜ ˜ S.L.U. All rights reserved. 2173-5794/© 2019 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana,
552
a r c h s o c e s p o f t a l m o l . 2 0 1 9;9 4(1 1):551–555
Emergencia hipertensiva
Ante la imposibilidad de realizar una angiografía fluoresceínica, la angiotomografía y las
Desprendimiento seroso de
imágenes en face-tomografía de coherencia óptica permitieron identificar las alteraciones
retina
vasculares en retina, coroides y coriocapilar.
Fallo renal
La angiotomografía y las imágenes en modo en face-tomografía de coherencia óptica
Angiotomografía
pueden ser de gran utilidad en la identificación de lesiones oftalmológicas vasculares rela-
Tomografía de coherencia
cionadas con la hipertensión maligna de aquellos casos en los que no sea posible realizar
óptica-en face
una angiografía fluoresceínica. ˜ ˜ S.L.U. Todos de Oftalmolog´ıa. Publicado por Elsevier Espana, © 2019 Sociedad Espanola los derechos reservados.
Introduction Malign arerial hypertension (AHT) is the severest form of AHT. It is defined by a severe elevation of arterial tension (AT) (diastolic tension above 130 mmHg) together with hypertensive retinopathy grade iii or iv, according to the Keith, Wagener and Barker classification (retinal hemorrhages and/or exudates, with or without papiledema).1,2 It has been recently proposed to include the failure of at least 3 target organs (kidneys, heart, brain and microangiopathy) with elevation of systolic and diastolic pressure beyond ranges.3 Hypertensive coroidopathy is an infrequent complication generally seen in young patients with severe and acute AT increase. It produces fibrinoid necrosis of choroidal arterioles and is characterized by diminished choriocapillary fusion with rupture of the outer blood-retina barrier and secondary serous retinal detachments.4 The objective of this paper is to describe the case of a 32-year-old male patient with malign AHT due to kidney transplant failure caused by laceration of a transplanted organ, exhibiting hypertensive choroidopathy, retinopathy and optical neuropathy.
Clinic case report A patient received kidney transplant due to chronic athy of unknown origin. Six days later trasplantectomy was performed due to graft laceration. On day 9 the patient exhibited severe AT elevation reaching 200/140 mmHg, referring sudden loss of vision in the right eye (RE) as symptom. Ophthalmological examination revealed serous detachment of the temporal-inferior retina with macular compromise, retinal venous dilatation, arteriolar atenuation, retinal hemorrhages and optic disc edema. The patient was administered dialysis and antihypertensive treatment, enabling control of AT. Fourteen days after the transplant, best corrected visual acuity was 0.1 in the RE and 0.8 in the left eye (LE). In the RE, the volume of the retinal serous detachment had diminished, presenting clinic compatible with Central retinal vein occlusion (venous dilatation and tortuosity, dispersed hemorrhages over the 4 quadrants and posterior pole, as well as macular edema). The LE only presented dilatation and venous tortuosity with slight arteriolar
attenuation, pathological arteriovenous crossings and some isolated hemorrhages. RE optical coherence tomography (OCT, DRI OCT Triton plus, Topcon Medical Systems, Inc., Oakland, New Jersey, USA) showed multiple subretinal fluid collections in the form of folds and pouches as well as significant macular destructuring. The LE did not exhibit alterations and presented a normal foveal profile. RE angiotomography (angio-OCT) evidenced extensive choriocapillary ischemia with significant reduction of the corresponding flow signal. In contrast, the LE exhibited very few choriocapillary perfusion alterations. Fluorescein angiography was not taken due to the poor clinic condition of the patient. After consulting with Nephrology, 3 intravitreal injections of antiangiogenic (bevacizumab) were administered at a rate of one per month during 3 months (Avastin® , Genentech, Inc, South San Francisco, California, USA) for treating the macular edema secondary to the retinal venous occlusion. After the –first injection, the patient exhibited clear RE fundus improvement with reduction of retinal edema, hemorrhages and foveal profile in OCT. Angio-OCT evidenced choriocapillary perfusion recovery and the presence of multiple hypo-reflectiveness lesion in the en face mode corresponding to focal pigment epitheliumning. Three months later, best corrected visual acuity was 0.5 in the RE and 1.0 in the LE. OCT showed focal ellipsoid interruptions whereas angio-OCT evidenced slight choriocapillary perfusion alteration. The hyper-reflective lesions of the previous examination in en face mode had disappeared. AGF no longer showed choroidal filling delay. However, hypo-fluorescent dotted lesions were visible during the entire angiogram which corresponded to the choroidal ischemia areas that were more evident in the RE (Figs. 1–3).
Discussion Severe systemic hypertension is associated to significant damages of target organs such as heart, central nervous system, kidneys and eyes.5 Hypertensive coroidopathy expresses in young patients with hypertensive crises, in females with preeclampsia and eclampsia as well as in pheochromocytoma or kidney
a r c h s o c e s p o f t a l m o l . 2 0 1 9;9 4(1 1):551–555
553
Fig. 1 – Right eye. A. macular OCT at diagnostic. DSR with formation of pouches and folds. B. Angio-OCT and en face mode. Extensive choriocapillary ischemia. C. capillary perfusion improvement. Hyper-reflective dotted lesions at the level of the RPE in en face mode (arrows). D. improvement observed at month 3 in retinopathy and OCT. Slight capillary perfusion reduction and disappearance of hypo-reflective RPE lesions in the en face mode.
failure cases. The basis of the choroidopathy is reduced choriocapillary circulation that could lead to choroidal and RPE ischemia.6 Its presence indicates a severe and acute increase of AT and could express in the course of undiagnosed hypertensive emergencies or in the context of a range of potentially severe systemic diseases7 requiring more intensive treatment including intravenous therapy. In the light of current knowledge, the inclusion of acute hypertensive coroidopathy should be considered for inclusion in the diagnostic criteria for malign hypertension. Development of angio-OCT has enabled a noninv asive technique for studying choroidal circulation which was previously the domain of indocyanine green angiography. Angio-OCT provides vascular flow information together
with structural data of conventional OCT. This technique is derived from the processing of signal intensity measurement repeated at the same point of the scanned area, enabling the differentiation of areas with flow from areas with static tissue.8 The case reported herein is a good example of the way in which OCT angio-OCT and en face-OCT enable the detection of outer retina alterations, RPE and choroids during the acute phase and the evolution of said patients, and is particularly of interest in cases in which angiography could be contraindicated. Accordingly, angio-OCT evidenced vascular compromise at the level of the choriocapillary as well as the recovery thereof during followup.
554
a r c h s o c e s p o f t a l m o l . 2 0 1 9;9 4(1 1):551–555
Fig. 2 – Left eye. A. OCT at diagnostic. B and C. OCT and angio-OCT at week 2 and month 3. Slightly diminished choriocapillary perfusion.
Fig. 3 – Retinography, autofluorescence and AGF taken at month 3. More acute pigment alterations in RE. Hyper-autofluorescent dotted lesions in RE (black arrows). Hypo-fluorescent lesions without changes in RE angiogram (white arrows).
Conflict of interests The authors declare the absence of any type of conflict of interests, that they have not received any financial support.
Acknowledgments The authors wish to acknowledge the Ophthalmology Society of Spain and its editors.
references
1. Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: Their course and prognosis. Am J Med Sci. 1974;268:336–45. 2. Ahmed ME, Walker JM, Beevers DG, Beevers M. Lack of difference between malignant and accelerated hypertension. Br Med J (Clin Res Ed). 1986;292:235–7. 3. Shantsila A, Lip GYH. Malignant hypertension revisited—Does this still exist? Am J Hypertens. 2017;30:543–9.
a r c h s o c e s p o f t a l m o l . 2 0 1 9;9 4(1 1):551–555
4. Hayreh SS, Servais GE, Virdi PS. Fundus lesions in malignanthypertension. VI. Hypertensive choroidopathy. Ophthalmology. 1986;93:1383–400. 5. Hirano Y, Yasukawa T, Ogura Y. Bilateral serous retinal detachments associated with accelerated hypertensive choroidopathy. Int J Hypertens. 2010;2010:964513, http://dx.doi.org/10.4061/2010/964513. ´ 6. Pociej-Marciak W, Karska-Basta I, Kuzniewski M, Kubicka-Trz˛aska A, Romanowska-Dixon B. Sudden visual deterioration as the first symptom of chronic kidney failure.
555
Case Rep Ophthalmol. 2015;6:394–400, http://dx.doi.org/10. 1159/000442182. 7. Stacey AW, Sozener CB, Besirli CG. Hypertensive emergencypresenting as blurry vision in a patient with hypertensive chorioretinopathy. Int J Emerg Med. 2015;8:13, http://dx.doi.org/10.1186/s12245-015-0063-6. 8. Coscas G, Lupidi M, Coscas F. Image analysis of optical coherence tomography angiography. Dev Ophthalmol. 2016;56:30–6.
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Hypertensive choroidopathy, retinopathy and optic neuropathy in renal transplantation failure夽 J.L. Sánchez-Vicente a , F. López-Herrero a , A.C. Martínez-Borrego a,∗ , B. Lechón-Caballero a , A. Moruno-Rodríguez a , F.E. Molina-Socola b a b
Oftalmología, Hospital Universitario Virgen del Rocío, Sevilla, Spain Oftalmología, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
A 32 year-old man who presented with severe elevation of blood pressure after failure of
Received 18 February 2019
kidney transplant. The patient had multiple serous retinal detachments, venous dilation,
Accepted 9 July 2019
arteriolar narrowing, retinal haemorrhages, as well as optic disc oedema.
Available online 8 October 2019
Due to the impossibility of performing a fluorescein angiography, an angiotomography and en-face optical coherence tomography images were used to identify the vascular alterations
Keywords: Hypertensive retinopathy Hypertensive choroidopathy Hypertensive optic neuropathy
in the retina, choroid, and choriocapillaris. Angiotomography and en face-optical coherence tomography mode images are very usefulin cases where it is not possible to perform fluorescein angiography. ˜ ˜ S.L.U. All rights de Oftalmolog´ıa. Published by Elsevier Espana, © 2019 Sociedad Espanola reserved.
Hypertensive emergency Retinal serous detachment Renal failure Angiotomography En face-optical coherence tomography
Coroidopatía, retinopatía y neuropatía óptica hipertensiva en un paciente con fracaso de trasplante renal r e s u m e n Palabras clave:
˜ Varón de 32 anos que presenta una elevación grave de la tensión arterial con cifras de
Retinopatía hipertensiva
200/140 mmHg tras fracaso de trasplante renal. Se observaron múltiples desprendimientos
Coroidopatía hipertensiva
serosos retinianos, dilatación venosa y atenuación de las arteriolas, hemorragias retinianas
Neuropatía óptica hipertensiva
y edema del disco óptico.
夽 Please cite this article as: Díez-Montero C, Fernández-Pérez GC, Galindo-Ferreiro A. Fístula orbitaria supratroclear secundaria a la realización de un bloqueo para anestesia en una cirugía de catarata. Arch Soc Esp Oftalmol. 2019;94:561–565. ∗ Corresponding author. E-mail address: [email protected] (A.C. Martínez-Borrego). ˜ ˜ S.L.U. All rights reserved. 2173-5794/© 2019 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana,
552
a r c h s o c e s p o f t a l m o l . 2 0 1 9;9 4(1 1):551–555
Emergencia hipertensiva
Ante la imposibilidad de realizar una angiografía fluoresceínica, la angiotomografía y las
Desprendimiento seroso de
imágenes en face-tomografía de coherencia óptica permitieron identificar las alteraciones
retina
vasculares en retina, coroides y coriocapilar.
Fallo renal
La angiotomografía y las imágenes en modo en face-tomografía de coherencia óptica
Angiotomografía
pueden ser de gran utilidad en la identificación de lesiones oftalmológicas vasculares rela-
Tomografía de coherencia
cionadas con la hipertensión maligna de aquellos casos en los que no sea posible realizar
óptica-en face
una angiografía fluoresceínica. ˜ ˜ S.L.U. Todos de Oftalmolog´ıa. Publicado por Elsevier Espana, © 2019 Sociedad Espanola los derechos reservados.
Introduction Malign arerial hypertension (AHT) is the severest form of AHT. It is defined by a severe elevation of arterial tension (AT) (diastolic tension above 130 mmHg) together with hypertensive retinopathy grade iii or iv, according to the Keith, Wagener and Barker classification (retinal hemorrhages and/or exudates, with or without papiledema).1,2 It has been recently proposed to include the failure of at least 3 target organs (kidneys, heart, brain and microangiopathy) with elevation of systolic and diastolic pressure beyond ranges.3 Hypertensive coroidopathy is an infrequent complication generally seen in young patients with severe and acute AT increase. It produces fibrinoid necrosis of choroidal arterioles and is characterized by diminished choriocapillary fusion with rupture of the outer blood-retina barrier and secondary serous retinal detachments.4 The objective of this paper is to describe the case of a 32-year-old male patient with malign AHT due to kidney transplant failure caused by laceration of a transplanted organ, exhibiting hypertensive choroidopathy, retinopathy and optical neuropathy.
Clinic case report A patient received kidney transplant due to chronic athy of unknown origin. Six days later trasplantectomy was performed due to graft laceration. On day 9 the patient exhibited severe AT elevation reaching 200/140 mmHg, referring sudden loss of vision in the right eye (RE) as symptom. Ophthalmological examination revealed serous detachment of the temporal-inferior retina with macular compromise, retinal venous dilatation, arteriolar atenuation, retinal hemorrhages and optic disc edema. The patient was administered dialysis and antihypertensive treatment, enabling control of AT. Fourteen days after the transplant, best corrected visual acuity was 0.1 in the RE and 0.8 in the left eye (LE). In the RE, the volume of the retinal serous detachment had diminished, presenting clinic compatible with Central retinal vein occlusion (venous dilatation and tortuosity, dispersed hemorrhages over the 4 quadrants and posterior pole, as well as macular edema). The LE only presented dilatation and venous tortuosity with slight arteriolar
attenuation, pathological arteriovenous crossings and some isolated hemorrhages. RE optical coherence tomography (OCT, DRI OCT Triton plus, Topcon Medical Systems, Inc., Oakland, New Jersey, USA) showed multiple subretinal fluid collections in the form of folds and pouches as well as significant macular destructuring. The LE did not exhibit alterations and presented a normal foveal profile. RE angiotomography (angio-OCT) evidenced extensive choriocapillary ischemia with significant reduction of the corresponding flow signal. In contrast, the LE exhibited very few choriocapillary perfusion alterations. Fluorescein angiography was not taken due to the poor clinic condition of the patient. After consulting with Nephrology, 3 intravitreal injections of antiangiogenic (bevacizumab) were administered at a rate of one per month during 3 months (Avastin® , Genentech, Inc, South San Francisco, California, USA) for treating the macular edema secondary to the retinal venous occlusion. After the –first injection, the patient exhibited clear RE fundus improvement with reduction of retinal edema, hemorrhages and foveal profile in OCT. Angio-OCT evidenced choriocapillary perfusion recovery and the presence of multiple hypo-reflectiveness lesion in the en face mode corresponding to focal pigment epitheliumning. Three months later, best corrected visual acuity was 0.5 in the RE and 1.0 in the LE. OCT showed focal ellipsoid interruptions whereas angio-OCT evidenced slight choriocapillary perfusion alteration. The hyper-reflective lesions of the previous examination in en face mode had disappeared. AGF no longer showed choroidal filling delay. However, hypo-fluorescent dotted lesions were visible during the entire angiogram which corresponded to the choroidal ischemia areas that were more evident in the RE (Figs. 1–3).
Discussion Severe systemic hypertension is associated to significant damages of target organs such as heart, central nervous system, kidneys and eyes.5 Hypertensive coroidopathy expresses in young patients with hypertensive crises, in females with preeclampsia and eclampsia as well as in pheochromocytoma or kidney
a r c h s o c e s p o f t a l m o l . 2 0 1 9;9 4(1 1):551–555
553
Fig. 1 – Right eye. A. macular OCT at diagnostic. DSR with formation of pouches and folds. B. Angio-OCT and en face mode. Extensive choriocapillary ischemia. C. capillary perfusion improvement. Hyper-reflective dotted lesions at the level of the RPE in en face mode (arrows). D. improvement observed at month 3 in retinopathy and OCT. Slight capillary perfusion reduction and disappearance of hypo-reflective RPE lesions in the en face mode.
failure cases. The basis of the choroidopathy is reduced choriocapillary circulation that could lead to choroidal and RPE ischemia.6 Its presence indicates a severe and acute increase of AT and could express in the course of undiagnosed hypertensive emergencies or in the context of a range of potentially severe systemic diseases7 requiring more intensive treatment including intravenous therapy. In the light of current knowledge, the inclusion of acute hypertensive coroidopathy should be considered for inclusion in the diagnostic criteria for malign hypertension. Development of angio-OCT has enabled a noninv asive technique for studying choroidal circulation which was previously the domain of indocyanine green angiography. Angio-OCT provides vascular flow information together
with structural data of conventional OCT. This technique is derived from the processing of signal intensity measurement repeated at the same point of the scanned area, enabling the differentiation of areas with flow from areas with static tissue.8 The case reported herein is a good example of the way in which OCT angio-OCT and en face-OCT enable the detection of outer retina alterations, RPE and choroids during the acute phase and the evolution of said patients, and is particularly of interest in cases in which angiography could be contraindicated. Accordingly, angio-OCT evidenced vascular compromise at the level of the choriocapillary as well as the recovery thereof during followup.
554
a r c h s o c e s p o f t a l m o l . 2 0 1 9;9 4(1 1):551–555
Fig. 2 – Left eye. A. OCT at diagnostic. B and C. OCT and angio-OCT at week 2 and month 3. Slightly diminished choriocapillary perfusion.
Fig. 3 – Retinography, autofluorescence and AGF taken at month 3. More acute pigment alterations in RE. Hyper-autofluorescent dotted lesions in RE (black arrows). Hypo-fluorescent lesions without changes in RE angiogram (white arrows).
Conflict of interests The authors declare the absence of any type of conflict of interests, that they have not received any financial support.
Acknowledgments The authors wish to acknowledge the Ophthalmology Society of Spain and its editors.
references
1. Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: Their course and prognosis. Am J Med Sci. 1974;268:336–45. 2. Ahmed ME, Walker JM, Beevers DG, Beevers M. Lack of difference between malignant and accelerated hypertension. Br Med J (Clin Res Ed). 1986;292:235–7. 3. Shantsila A, Lip GYH. Malignant hypertension revisited—Does this still exist? Am J Hypertens. 2017;30:543–9.
a r c h s o c e s p o f t a l m o l . 2 0 1 9;9 4(1 1):551–555
4. Hayreh SS, Servais GE, Virdi PS. Fundus lesions in malignanthypertension. VI. Hypertensive choroidopathy. Ophthalmology. 1986;93:1383–400. 5. Hirano Y, Yasukawa T, Ogura Y. Bilateral serous retinal detachments associated with accelerated hypertensive choroidopathy. Int J Hypertens. 2010;2010:964513, http://dx.doi.org/10.4061/2010/964513. ´ 6. Pociej-Marciak W, Karska-Basta I, Kuzniewski M, Kubicka-Trz˛aska A, Romanowska-Dixon B. Sudden visual deterioration as the first symptom of chronic kidney failure.
555
Case Rep Ophthalmol. 2015;6:394–400, http://dx.doi.org/10. 1159/000442182. 7. Stacey AW, Sozener CB, Besirli CG. Hypertensive emergencypresenting as blurry vision in a patient with hypertensive chorioretinopathy. Int J Emerg Med. 2015;8:13, http://dx.doi.org/10.1186/s12245-015-0063-6. 8. Coscas G, Lupidi M, Coscas F. Image analysis of optical coherence tomography angiography. Dev Ophthalmol. 2016;56:30–6.