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A previously healthy African American man in his 20s presented to the emergency department after referral by an optometrist for “bleeding in the back of the eye.” The patient noted that 2 months prior he began experiencing throbbing headaches in the back of his head that were more painful and associated with lightheadedness when laying down. Two weeks prior to presentation, he started noticing black spots in his peripheral vision and progressive blurring of vision in both eyes. The patient denied recent travel, cough, gastrointestinal or genitourinary tract symptoms, ulcers, aching joints, tinnitus, or transient visual obscurations. He reported owning cats.
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Papilledema secondary to intracranial venous sinus stenosis, exacerbated by hypertensive emergency
D. All of the above
Optic nerve edema can result from several causes. In this patient, hypertensive papillitis, neuroretinitis, and papilledema from intracranial hypertension were all in the differential diagnosis. Therefore, all of the above testing (choice D) was warranted to ensure a timely and accurate diagnosis. In the setting of hypertensive emergency, the patient was admitted for control of blood pressure and treatment of systemic sequelae. Hypertensive papillitis can present with macular exudation and optic nerve head edema.1 However, concluding that systemic hypertension was the sole underlying cause of the optic nerve head swelling would be inadequate management (choice A). No further update is available for suspected renal artery stenosis as an underlying cause for his malignant hypertension, as the patient is lost to follow-up.
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Corresponding Author: Peter W. MacIntosh, MD, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W Taylor St, Chicago, IL 60612 (email@example.com).
Published Online: January 31, 2019. doi:10.1001/jamaophthalmol.2018.5902
Conflict of Interest Disclosures: Dr Zahid reported serving as a consultant for Allergan outside the submitted work. No other disclosures were reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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