International Journal of Retina (IJRETINA) 2018, Volume 1, Number 1.

P-ISSN. 2614-8684, E-ISSN.2614-8536

BILATERAL EXUDATIVE RETINAL DETACHMENT DUE TO

HYPERTENSIVE RETINOPATHY AND CHOROIDOPATHY IN
YOUNG PATIENT WITH CHRONIC KIDNEY DISEASE
Indha Dwi Kartikasari, Nadia Artha Dewi, Mirza Metita, Safaruddin Refa
Department of Ophthalmology, Universitas Brawijaya, Saiful Anwar Hospital Malang

ABSTRACT
Introduction: Severe systemic hypertension in chronic kidney disease can cause significant damage to the
eye. Although hypertensive retinopathy is a well-known complication, hypertensive optic neuropathy and
choroidopathy are much less common. The aim of this study is to report retinal manifestation in young
patient with chronic kidney disease.

Method: A 26-year-old man with underlying disease chronic kidney disease (CKD) gr-V underwent bilateral
bullous exudative retinal detachments. Retinal arteriolar narrowing, vascular tortuosity, arteriovenous
nicking, optic disc swelling, retinal haemorrhage, elschnig spot, siegrist streak were identified in both eyes.
Blood pressure was 200/140mmHg with visual acuity 0,5/60 OU. The patient was diagnosed with bilateral
hypertensive retinopathy and choroidopathy with bulous exudative retinal detachments.

Results: After antihypertensive treatment, visual acuity improved, but the exudative retinal detachments
and retinal hemorrhages reduced. A patient with those findings should be considered as having
hypertensive retinopathy and choroidopathy and treated as soon as possible because of the poor
prognostic.

Conclusion: Hypertensive choroidopathy is a rare finding associated with acute increases in blood pressure.
When the choroid is associated, the hypertensive event is often more acute and associated with increased
morbidity. It is necessary to obtain fundus exam in any patient with elevated blood pressure and
concomitant vision complaints. Therefore, screening hypertensive patients involves close collaboration
between internist and ophthalmologist.

Keywords: Hypertensive choroidopathy, hypertensive retinopathy, exudative retinal detachment, elschnig’s spot,
siegrist streak, chronic kidney disease
Cite This Article: KARTIKASARI, indha dwi; DEWI, Nadia Artha. Bilateral Exudative Retinal Detachment Due to
Hypertensive Retinopathy and Choroidopathy In Young Patient with Chronic Kidney Disease. International Journal of
Retina, [S.l.], v. 1, n. 1, july 2018. ISSN 2614-8536. Available at:
<https://www.ijretina.com/index.php/ijretina/article/view/20>

INTRODUCTION
Severe systemic hypertension in chronic development of a macular star configuration of
kidney disease can cause significant damage to intraretinal lipid can be seen1–3. When the
the eye. Although hypertensive retinopathy is choroidal vessels are severely affected by
*Correspondence to: a well-known complication, hypertensive elevated blood pressure, as in acute
Indha Dwi Kartikasari, neuropathy and choroidopathy are much less hypertension, fibrinoid necrosis of choroidal
Department of Ophthalmology,
common. Elevation of systemic blood pressure arterioles can cause occlusion of areas of
Universitas Brawijaya,
[email protected]
as in renovascular disease causes both focal choriocapillaris, with a subsequent breakdown
and generalized retinal arteriolar constriction, of the outer blood-retinal barrier. Although the
presumably mediated by autoregulation. A retinal vascular changes and optic neuropathy
prolonged duration of particularly high blood are well known, hypertensive choroidopathy
pressure can be associated with a breakdown usually does not receive as much attention.
of the inner blood-retinal barrier, with Hypertensive choroidopathy has been reported
extravasation of plasma and red blood cells. in toxemia of pregnancy, renal disease,
Retinal hemorrhages, cottonwool spots, pheochromocytoma, and malignant
intraretinal lipid, and, in severe cases, the hypertension4.
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Hypertension retinopathy occur almost half in CKD retinal hemorrhage, intraretinal exudation and macular
population, while hypertension choroidopathy only on star formation, exudative retinal detachment, Elsching
0,1%5. We report a case of hypertensive retinopathy and spot, and Siegrist streak. The blood pressure was 200/140
hypertensive choroidopathy with bilateral exudative mmHg. Hemoglobin 8,0 g/dL, RBC 2,96 x 106/µL, WBC
retinal detachments in young patient with chronic kidney 13.130/µL, hematocrit 24,10%, PLT 114.000/µL, RBS 150
disease. mg/dL, ureum 249,70 mg/dL, creatinin 20,61mg/dL.
Urinalysis pH 8,5; density 1,015; glucose1+; protein 3+;
CASE ILLUSTRATION keton, bilirubin, urobilinogen, nitrit negative; WBC 2+,
A 26-year-old man presented with a painless loss of blood 3+; epithel 1,1 LPK, cylinder negative; RBC 41,9 LPB;
vision in his both eyes. He had a history of chronic kidney WBC 46,5 LPB, crystal negative, bacteria 2750,8 x 10 3 /mL,
disease (CKD) gr-V on hemodyalisis since 2 months ago. shown in the laboratory result. The patient was diagnosed
Ophthalmic examination revealed visual acuity of 0.5/60 with bilateral hypertensive retinopathy and
OU. Pupils reacted normally without an afferent pupillary choroidopathy with bullous exudative retinal detachment
defect. He had normal extraocular motility, and ocular and treated with antihypertensive treatment glyceryl
alignment in both eyes. Slit lamp examination revealed trinitrate (GTN) drip 20-200 µ /mnt and furosemide drip
subconjunctival haemorrhage in both eyes. Retinal 10 mg/hour, amlodipine 1x10 mg tab, valsartan 1x80 mg
examination revealed retinal arteriolar narrowing, vascular tab, lansoprazole 1x30 mg intravena (iv), and
tortuosity, arteriovenous nicking, optic disc swelling, metoclopramide 3x10 mg iv.

Figure 1. Subkonjungtival Haemorrhage on Both Eyes

Figure 2. Fundus Photograhy Show Bilateral Disc Edema, Retinal Bleeding, Exudative Retinal Detachment, Elschnig Spot,
Siegrist Streak , and Macular Star (Courtesy By Vitreo-Retina Division)

Patient came at outpatient clinic after 2 weeks with improvement in visual acuity to 1/60 with better retinal
findings, but decreasing in general condition. According to systemic condition, 2 weeks later the patient passed away.

Figure 3. There Were Reducing of Subconjunctival Haemorrhage on Both Eyes After 3 Weeks
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 Figure 4. Fundus Photography After 3 Weeks Show Reducing Of Bilateral Disc Edema, Retinal Bleeding, And Exudative
Retinal Detachment(Courtesy by Vitreo-retina Division)

Figure 5. Ocular USG Right Eye (Above) Left Eye (Below) When Sitting Postion (Left Photo) and Supine Position (Right
Photo) Showed Shifting Fluid As Gravitation. (Courtesy By Vitreo-Retina Division)

DISCUSSION ischemia, which causes hypertensive choroidopathy.

Severe systemic hypertension is associated with Some of these are attributed to a breakdown of the inner
significant damage of end organs, such as eyes, heart, blood-retinal barrier with retinal endothelial cell
central nervous system, and kidneys. Choroidal lesions are decompensation. Furthermore, there are large
less commonly recognized than retinal and optic nerve fenestrations in the walls of the choriocapillaris, so the
lesions6. Subconjunctival haemorrhage associated with choroidal vascular bed has no blood ocular barrier. This
valsava maneuver and drastically increased blood causes leakage of plasma into the choroidal fluid.
pressure7. Accelerated hypertension and/or Angiotensin II and other vasoconstrictors in the choroidal
ophthalmic/ciliary artery occlusion may result in choroidal fluid result in vasoconstriction and ischemia of the
ischemia. With complete ophthalmic artery occlusion, choroidal vasculature. This cascade is followed by RPE
both the retinal and choroidal circulations are ischemia and the subsequent breakdown of the blood
compromised. Compromise of ciliary arteries may occur retinal barrier in the RPE and result as Elcshnig spot and
without retinal artery involvement, leading to choroidal

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Hypertensive choroidopathy is a rare finding associated
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This work licensed under Creative Commons Attribution
obtain a fundus exam in any patient with elevated blood
pressure and concomitant vision complaints. Therefore,
screening hypertensive patients involves close
collaboration between internist and ophthalmologist.
Antihypertensive is the first line treatment, but if the
exudative retinal detachment not resolve and retinal
detachment is chronic and bullous, surgical intervention
to drain the fluid can be planned.

36 Published by : INAVRS https://www.inavrs.org/ | International Journal of Retina https://ijretina.com 2018; 1; 1;