Hypertensive Retinopathy and Choroidopathy: 30-Item MCQ Case Series for Retina Fellowship Board Examination
Case 1
A 52-year-old woman presents with sudden bilateral vision loss. Blood pressure is 230/130 mmHg. Fundoscopy reveals bilateral flame-shaped hemorrhages, cotton wool spots, and papilledema.
Question 1: What is the most appropriate initial management?
A. Oral amlodipine and outpatient follow-up
B. Immediate ICU admission with IV labetalol or nicardipine
C. Observation for 24 hours then reassess
D. Intravitreal anti-VEGF injection
Answer: B
Explanation: This patient has Grade III/IV hypertensive retinopathy with blood pressure >200/120 mmHg, representing a hypertensive emergency requiring immediate ICU admission with IV labetalol or nicardipine. 1 The goal is to reduce mean arterial pressure by 20-25% over the first hour. 1, 2 Advanced retinopathy with flame-shaped hemorrhages, cotton wool spots, and papilledema indicates malignant hypertension requiring emergency management. 3, 1 Oral agents are insufficient for hypertensive emergencies with acute end-organ damage. 3
Case 2
A 45-year-old man with no known medical history presents with painless vision loss in the left eye. Blood pressure is 220/120 mmHg. OCT shows exudative retinal detachment. The right eye fundus appears normal.
Question 2: What is the most likely diagnosis?
A. Rhegmatogenous retinal detachment
B. Central serous chorioretinopathy
C. Hypertensive choroidopathy
D. Diabetic tractional retinal detachment
Answer: C
Explanation: Hypertensive choroidopathy with exudative retinal detachment can be the sole manifestation of malignant hypertension, even presenting unilaterally. 4 Severe blood pressure elevation >200/120 mmHg causes autoregulation failure in choroidal vessels, leading to endothelial damage and breakdown of the blood-retinal barrier, resulting in choroidal vascular leakage and subretinal fluid accumulation. 2 The absence of pre-existing systemic disease history does not exclude malignant hypertension. 4 Unilateral presentation is possible, though bilateral findings are more typical. 1, 4
Case 3
During fundoscopy of a patient with blood pressure 210/125 mmHg, you observe bilateral arteriovenous nicking and generalized arteriolar narrowing without hemorrhages.
Question 3: What grade of hypertensive retinopathy is this?
A. Grade I
B. Grade II
C. Grade III
D. Grade IV
Answer: B
Explanation: Arteriovenous nicking is a characteristic feature of Grade II hypertensive retinopathy. 1 Generalized or focal narrowing of retinal arterioles without hemorrhage represents mild to moderate hypertensive retinopathy. 1 Grade II retinopathy indicates elevated cardiovascular risk with an odds ratio of 4.2 for coronary artery disease, requiring aggressive cardiovascular risk modification. 1 Grade III/IV would include flame-shaped hemorrhages, cotton wool spots, hard exudates, or papilledema. 3, 1
Case 4
A 28-year-old woman at 34 weeks gestation presents with blood pressure 190/115 mmHg and bilateral flame-shaped hemorrhages on fundoscopy.
Question 4: What does the presence of retinopathy indicate?
A. Gestational hypertension
B. Chronic hypertension with superimposed preeclampsia
C. Eclampsia
D. Normal pregnancy-related changes
Answer: B
Explanation: Retinopathy in a hypertensive pregnant patient indicates chronic hypertension with superimposed preeclampsia, not gestational hypertension alone. 1 The presence of retinopathy is highly indicative of chronic hypertension because retinal changes develop from prolonged vascular damage and autoregulation failure requiring sustained severe blood pressure elevation over time. 1 Advanced retinopathy with flame-shaped hemorrhages typically occurs with blood pressure >200/120 mmHg and represents malignant hypertension—a condition that develops from chronic uncontrolled hypertension, not acute gestational hypertension. 1
Case 5
A patient with malignant hypertension shows exudative retinal detachment on OCT. OCTA reveals focal dark areas in the choriocapillaris slab.
Question 5: What do the OCTA findings represent?
A. Artifact from poor image quality
B. Flow signal voids indicating regions of non-perfusion
C. Normal choriocapillaris appearance
D. Drusen
Answer: B
Explanation: OCTA manifests focal dark areas in the choriocapillaris slab corresponding to flow signal voids, signifying regions of non-perfusion in hypertensive choroidopathy. 4 These areas of non-perfusion correlate with late indocyanine green angiography-presumed choroidal ischemia. 5 OCTA is an essential tool in the diagnosis and follow-up of patients with hypertensive choroidopathy, revealing areas of non-perfusion at the choriocapillaris level. 4 Early diagnosis using OCTA prevents permanent RPE damage and leads to complete choroidal remodeling with better visual outcomes. 4
Case 6
A 60-year-old diabetic patient with blood pressure 165/95 mmHg develops worsening diabetic retinopathy over 6 months.
Question 6: What is the relationship between hypertension and diabetic retinopathy?
A. Hypertension has no effect on diabetic retinopathy
B. Hypertension is a major risk factor for diabetic retinopathy development and progression
C. Hypertension only affects non-diabetic retinopathy
D. Hypertension protects against diabetic retinopathy
Answer: B
Explanation: High blood pressure increases the risk of both development of diabetic retinopathy and its progression. 6 Adequate control of blood pressure has been proven in randomized clinical trials to reduce vision loss associated with diabetic retinopathy. 6 Hypertension acts as a risk factor for diabetic retinopathy progression through microvascular damage mechanisms. 2 However, hypertension does not directly cause tractional retinal detachment, which is distinct from the exudative detachment seen in hypertensive choroidopathy. 2
Case 7
During fluorescein angiography of a patient with malignant hypertension, you observe hyperfluorescent spots with leakage in late phases.
Question 7: What do these findings represent?
A. Normal fluorescein pattern
B. Choroidal neovascularization
C. Elschnig spots from choriocapillaris occlusion
D. Retinal arterial macroaneurysms
Answer: C
Explanation: Fluorescein angiography showing hyperfluorescent spots with leakage in late phases represents Elschnig spots, which are yellow demarcated lesions in the perimacular region that leak fluorescein after occlusion of the choriocapillaris. 7 When Elschnig spots heal, a pigment spot is left surrounded by a depigmented pale halo. 7 These are manifestations of hypertensive choroidopathy, which is less common than retinal hemorrhages and infarcts seen with accelerated hypertension. 7 Elschnig spots confirm choroidal involvement in malignant hypertension. 4, 7
Case 8
A patient with blood pressure 235/130 mmHg requires immediate treatment. What is the target blood pressure reduction in the first hour?
Question 8: What is the appropriate initial blood pressure target?
A. Normalize to 120/80 mmHg immediately
B. Reduce mean arterial pressure by 20-25% over the first hour
C. Reduce to 140/90 mmHg within 30 minutes
D. No reduction needed if asymptomatic
Answer: B
Explanation: Immediate blood pressure reduction requires reducing mean arterial pressure by 20-25% over the first hour using intravenous agents in hypertensive emergencies. 1, 2 After initial reduction, target diastolic blood pressure of 100-110 mmHg over 24 hours. 2, 8 Avoid excessive rapid lowering, which can cause cerebral infarction, myocardial damage, or renal hypoperfusion. 2, 8 The controlled reduction prevents ischemic complications while limiting extension of acute hypertension-mediated organ damage. 3
Case 9
A 51-year-old woman with no past medical history presents with painless vision loss in the left eye only. Blood pressure is 220/120 mmHg. Only exudative retinal detachment is found in the left eye.
Question 9: What is the significance of unilateral presentation?
A. Rules out hypertensive etiology
B. Hypertensive choroidopathy can present unilaterally as the sole finding
C. Indicates embolic cause
D. Requires immediate vitrectomy
Answer: B
Explanation: Hypertensive choroidopathy with exudative retinal detachment can be the only sign of malignant hypertension and can present unilaterally, with no pre-existing history of systemic disease required. 4 While bilateral presentation is highly specific for chronic hypertensive etiology, one eye may be more severely affected initially. 1, 8 The unilateral nature does not exclude hypertensive choroidopathy when blood pressure is severely elevated. 4 Complete blood work-up should be performed to exclude other etiologies. 4
Case 10
A patient with malignant hypertension shows linear hyperpigmented streaks over choroidal arteries on fundoscopy.
Question 10: What are these findings called?
A. Elschnig spots
B. Siegrist streaks
C. Roth spots
D. Hollenhorst plaques
Answer: B
Explanation: Siegrist streaks are linear hyperpigmented streaks over choroidal arteries, representing a manifestation of hypertensive choroidopathy. 7 These findings, along with Elschnig spots and serous retinal detachment, constitute the classic triad of choroidal involvement in malignant hypertension. 7 Hypertensive choroidopathy has been reported in toxemia of pregnancy, renal disease, pheochromocytoma, and malignant hypertension. 7 Siegrist streaks indicate chronic choroidal vascular damage from sustained severe hypertension. 7
Case 11
A 25-year-old woman with terminal renal insufficiency and blood pressure 190/135 mmHg presents with bilateral vision loss. Fundoscopy shows deep yellow spots bilaterally with slight pigment epithelium detachments.
Question 11: What imaging modality best identifies choriocapillaris non-perfusion?
A. Fluorescein angiography alone
B. Wide-field swept-source OCT angiography
C. B-scan ultrasonography
D. Fundus photography
Answer: B
Explanation: Wide-field swept-source OCT angiography (SS-OCTA) is capable of showing choroidal vascularization impairment in hypertensive retinopathy by identifying areas of non-perfusion of the choriocapillaris. 5 SS-OCTA shows multiple and widespread flow voids on the choriocapillaris slabs, corresponding to areas of hypofluorescence on indocyanine green angiography. 5 These areas mostly correlate with late ICGA-presumed choroidal ischemia. 5 SS-OCTA used alone can demonstrate associated hypertensive choroidopathy without requiring invasive dye-based angiography. 5
Case 12
A patient with Grade II hypertensive retinopathy asks about cardiovascular risk.
Question 12: What is the odds ratio for coronary artery disease in patients with Grade II retinopathy?
A. 1.5
B. 2.1
C. 4.2
D. 6.8
Answer: C
Explanation: Patients with Grade II retinopathy are at elevated cardiovascular risk with a reported odds ratio of 4.2 for coronary artery disease. 1 Signs of hypertensive retinopathy are predictive of incident stroke, congestive heart failure, and cardiovascular mortality—independently of traditional risk factors. 6 Grade II retinopathy requires aggressive cardiovascular risk modification beyond blood pressure control alone. 1 Recognition of ocular effects allows physicians to better manage patients with hypertension and monitor end-organ effects. 6
Case 13
A 35-year-old man with blood pressure 215/125 mmHg presents with sudden vision loss. You suspect malignant hypertension.
Question 13: What percentage of malignant hypertension cases have secondary causes?
A. 5-10%
B. 20-40%
C. 50-60%
D. 70-80%
Answer: B
Explanation: In patients presenting with malignant hypertension, secondary causes can be found in 20-40%, most often consisting of renal parenchymal disease and renal artery stenosis. 3 Endocrine causes appear to be rare. 3 However, the majority of patients with malignant hypertension have unrecognized or uncontrolled essential hypertension. 3 Young patients with malignant hypertension require investigation for secondary causes including complete blood count, comprehensive metabolic panel, and urinalysis with albumin-to-creatinine ratio to assess for renal disease. 8
Case 14
A patient with hypertensive emergency shows papilledema on fundoscopy. What percentage of patients with malignant hypertension develop hypertensive encephalopathy?
Question 14: What is the incidence of hypertensive encephalopathy in malignant hypertension?
A. 1-5%
B. 10-15%
C. 25-30%
D. 40-50%
Answer: B
Explanation: Hypertensive encephalopathy occurs in 10-15% of patients presenting with malignant hypertension. 3 However, advanced hypertensive retinopathy may be lacking in up to one-third of these patients. 3 The diagnosis principally relies on the presence of neurological symptoms supported by additional imaging. 3 Seizures, lethargy, cortical blindness, and coma are among the most alarming symptoms, but more subtle neurological features can be present at an earlier stage. 3
Case 15
A patient with blood pressure 175/105 mmHg has mild arteriolar narrowing without hemorrhages or exudates.
Question 15: What is the appropriate management?
A. Immediate ICU admission
B. IV antihypertensive agents
C. Outpatient management with oral antihypertensives and close follow-up within 24-48 hours
D. Observation only without treatment
Answer: C
Explanation: Patients with mild retinopathy without hemorrhages can be managed as outpatients with aggressive oral antihypertensive therapy and close follow-up within 24-48 hours. 8 Patients that lack acute hypertension-mediated end organ damage to the heart, retina, brain, kidneys, or large arteries do not have a hypertensive emergency and can be treated with oral BP-lowering agents. 3 Target blood pressure is <140/90 mmHg in mild retinopathy without hemorrhages, with comprehensive cardiovascular risk assessment and lifestyle modifications. 1 Long-term target is <130/80 mmHg. 8
Case 16
During follow-up of a patient with hypertensive choroidopathy, blood pressure normalizes over 9 months.
Question 16: What happens to choriocapillaris perfusion with blood pressure normalization?
A. Remains permanently impaired
B. Partially improves but never normalizes
C. Completely restored
D. Worsens despite blood pressure control
Answer: C
Explanation: During follow-up with blood pressure normalization, choriocapillaris perfusion can be completely restored. 4 Early diagnosis prevents permanent damage of the RPE and leads to complete choroidal remodeling and better visual outcomes. 4 The choriocapillaris flow improves as blood pressure normalizes. 5 This demonstrates the reversibility of choroidal vascular changes when hypertension is adequately controlled, emphasizing the importance of prompt diagnosis and treatment. 4, 5
Case 17
A 67-year-old African-American male with untreated hypertension, hyperlipidemia, and diabetes presents with sudden progressive vision loss over 8 days. Ophthalmologic exam confirms central retinal artery occlusion without visible embolus.
Question 17: What is the most likely underlying etiology?
A. Cardiac embolism
B. Carotid artery stenosis
C. Primary hypertension causing arterial occlusion
D. Giant cell arteritis
Answer: C
Explanation: Extensive workup revealing no embolic source postulates primary hypertension as the underlying etiology for central retinal artery occlusion in this patient. 9 Untreated systemic hypertension is associated with retinopathy, optic neuropathy, and choroidopathy. 7 Hypertension is a major risk factor for the development of retinal vascular diseases, such as retinal vein and artery occlusion, and ischemic optic neuropathy. 6 MRI can reveal restricted diffusion within the distal optic nerve, illustrating more proximal occlusion in hypertensive patients. 9
Case 18
A patient with malignant hypertension requires first-line IV antihypertensive therapy.
Question 18: Which medications are first-line IV agents for hypertensive emergency with retinopathy?
A. Hydralazine or nitroprusside
B. Labetalol, nicardipine, or clevidipine
C. Enalaprilat or esmolol
D. Furosemide or hydrochlorothiazide
Answer: B
Explanation: First-line medications for hypertensive emergency with advanced retinopathy are labetalol, nicardipine, or clevidipine. 1 These agents allow controlled reduction of mean arterial pressure by 20-25% over the first hour. 1, 2 IV labetalol or nicardipine should be used for immediate ICU admission in patients with blood pressure >200/120 mmHg with advanced retinopathy (Grade III/IV). 1, 8 These agents provide titratable blood pressure control while minimizing risk of excessive rapid lowering. 1
Case 19
A patient asks whether hypertensive retinopathy typically affects one or both eyes.
Question 19: What is the typical laterality of hypertensive retinopathy?
A. Always unilateral
B. Typically bilateral, though one eye may be more severely affected initially
C. Alternating between eyes
D. Random distribution
Answer: B
Explanation: Hypertensive retinopathy classically affects both eyes bilaterally, but a patient may notice symptoms in only one eye initially, or one eye may be more severely affected. 1, 8 The bilateral presence of findings is highly specific for hypertensive etiology. 1, 8 Bilateral presentation of hypertensive retinopathy is highly specific for chronic hypertensive etiology, indicating target organ damage from chronic hypertension. 1 However, unilateral presentation does not exclude the diagnosis when blood pressure is severely elevated. 4
Case 20
A patient with blood pressure 240/135 mmHg shows Grade IV retinopathy with papilledema.
Question 20: What is the typical blood pressure threshold for advanced retinopathy with hemorrhages?
A. >140/90 mmHg
B. >160/100 mmHg
C. >180/110 mmHg
D. >200/120 mmHg
Answer: D
Explanation: Blood pressure is typically severely elevated (>200/120 mmHg) when hemorrhages and advanced retinopathy occur. 1 Advanced hypertensive retinopathy (Grade III/IV) represents a hypertensive emergency requiring immediate intervention, characterized by flame-shaped hemorrhages, cotton wool spots, hard exudates, and papilledema. 1 A typical example of hypertensive emergency is the coexistence of very high BP values (often >200/120 mmHg) with advanced retinopathy. 3 This threshold indicates malignant hypertension with acute end-organ damage. 3, 1
Case 21
A patient with hypertensive choroidopathy undergoes multimodal imaging including ICGA.
Question 21: What do areas of hypofluorescence on late ICGA represent?
A. Normal choroidal perfusion
B. Choroidal ischemia and non-perfusion
C. Choroidal neovascularization
D. Retinal pigment epithelium hypertrophy
Answer: B
Explanation: Areas of hypofluorescence on late indocyanine green angiography represent presumed choroidal ischemia and non-perfusion in hypertensive choroidopathy. 5 These areas correlate with flow voids on SS-OCTA choriocapillaris slabs. 5 The hypofluorescent areas demonstrate choroidal vascular impairment from autoregulation failure and endothelial damage caused by severe blood pressure elevation. 2, 5 Multimodal imaging shows characteristic features of choroidal involvement in hypertension. 5
Case 22
A young patient with malignant hypertension shows white areas in the iris suggesting ocular ischemia.
Question 22: What does bilateral iris involvement indicate?
A. Unrelated ocular pathology
B. Highly specific for chronic systemic hypertension
C. Acute angle-closure glaucoma
D. Infectious uveitis
Answer: B
Explanation: The bilateral presence of ocular findings is highly specific for chronic systemic hypertension and indicates significant cardiovascular risk requiring comprehensive evaluation. 8 Malignant hypertension causes autoregulation failure in ocular vessels, leading to endothelial damage and ischemic changes that can manifest as white areas in the iris. 8 The bilateral nature of findings would be highly specific for chronic hypertensive etiology, though one eye may be more severely affected initially. 1, 8 This indicates target organ damage from prolonged vascular injury. 1, 8
Case 23
A patient with hypertensive emergency requires monitoring during treatment.
Question 23: What is the appropriate setting for initial management of Grade III/IV retinopathy with blood pressure >200/120 mmHg?
A. Outpatient clinic
B. Emergency department observation unit
C. General medical ward
D. Intensive care unit
Answer: D
Explanation: Immediate ICU admission is required for patients with blood pressure >200/120 mmHg with advanced retinopathy (Grade III/IV). 1, 8 Patients with hypertensive emergency should be admitted for close monitoring and treated with intravenous blood pressure-lowering agents to reach the recommended BP target in the designated time-frame. 3 ICU admission allows continuous blood pressure monitoring and titration of IV antihypertensive agents. 1 This prevents complications from excessive rapid lowering while ensuring adequate reduction of mean arterial pressure. 1, 8
Case 24
A patient with malignant hypertension shows cotton wool spots on fundoscopy.
Question 24: What do cotton wool spots represent pathophysiologically?
A. Lipid exudates
B. Retinal nerve fiber layer infarcts from microvascular occlusion
C. Choroidal neovascularization
D. Vitreous hemorrhage
Answer: B
Explanation: Cotton wool spots represent retinal nerve fiber layer infarcts resulting from microvascular occlusion and leakage in hypertensive retinopathy. 1 These are characteristic features of Grade III/IV advanced hypertensive retinopathy. 1 Endothelial damage from high shear forces leads to vessel wall injury and microvascular occlusion. 1 Cotton wool spots, along with flame-shaped hemorrhages, hard exudates, and papilledema, indicate malignant hypertension requiring emergency management. 3, 1
Case 25
A patient with hypertensive retinopathy requires long-term blood pressure management after acute treatment.
Question 25: What is the long-term target blood pressure after resolution of hypertensive emergency?
A. <140/90 mmHg
B. <130/80 mmHg
C. <120/70 mmHg
D. <110/60 mmHg
Answer: B
Explanation: Long-term target blood pressure is <130/80 mmHg after resolution of hypertensive emergency. 8 Initial management targets diastolic blood pressure of 100-110 mmHg over 24 hours, but long-term control requires more aggressive targets. 2, 8 Target blood pressure <140/90 mmHg applies to mild retinopathy without hemorrhages, but patients with history of malignant hypertension require tighter control. 1, 8 This prevents recurrence of hypertensive end-organ damage and reduces cardiovascular risk. 1, 6
Case 26
A patient with hypertensive choroidopathy shows improvement on follow-up imaging.
Question 26: What is the clinical significance of early diagnosis in hypertensive choroidopathy?
A. No impact on outcomes
B. Prevents permanent RPE damage and leads to complete choroidal remodeling
C. Only cosmetic benefit
D. Prevents glaucoma development
Answer: B
Explanation: Early diagnosis prevents permanent damage of the RPE and leads to complete choroidal remodeling and better visual outcomes in hypertensive choroidopathy. 4 With blood pressure normalization, patients can regain visual function and choriocapillaris perfusion can be completely restored. 4 OCTA is an essential tool for early diagnosis and follow-up, revealing areas of non-perfusion at the choriocapillaris level. 4 Delayed diagnosis may result in irreversible RPE damage and permanent vision loss. 4
Case 27
A patient with suspected hypertensive emergency presents to the emergency department.
Question 27: What proportion of patients presenting to the ED with suspected hypertensive emergency actually have a true hypertensive emergency based on current definitions?
A. 1 in 10
B. 1 in 5
C. 1 in 2 to 3
D. All patients
Answer: C
Explanation: Based on current definitions, approximately one in every two to three patients presenting with suspected hypertensive emergency have a true hypertensive emergency. 3 One in every 200 patients presents at the ED with suspected hypertensive emergency. 3 The distinction depends on presence of acute hypertension-mediated end organ damage to the heart, retina, brain, kidneys, or large arteries. 3 Patients lacking acute end-organ damage do not have a hypertensive emergency and can be treated with oral BP-lowering agents. 3
Case 28
A patient with malignant hypertension requires workup for secondary causes.
Question 28: What is the most common secondary cause of malignant hypertension?
A. Pheochromocytoma
B. Primary aldosteronism
C. Renal parenchymal disease and renal artery stenosis
D. Cushing syndrome
Answer: C
Explanation: Secondary causes of malignant hypertension most often consist of renal parenchymal disease and renal artery stenosis, found in 20-40% of cases. 3 Endocrine causes appear to be rare. 3 Young patients with malignant hypertension require complete blood count, comprehensive metabolic panel, urinalysis with albumin-to-creatinine ratio to assess for renal disease, and ECG to evaluate for cardiac end-organ damage. 8 Despite secondary causes being common, the majority of patients have unrecognized or uncontrolled essential hypertension. 3
Case 29
A patient with hypertensive retinopathy asks about the mechanism of retinal damage.
Question 29: What is the primary pathophysiological mechanism causing hypertensive retinopathy?
A. Retinal vein thrombosis
B. Autoregulation failure with endothelial damage from high shear forces
C. Choroidal neovascularization
D. Vitreous traction
Answer: B
Explanation: The pathophysiology involves autoregulation failure in retinal vessels when blood pressure exceeds the capacity of vessels to compensate, with endothelial damage from high shear forces leading to vessel wall injury and bleeding. 1 Microvascular occlusion and leakage result in flame-shaped hemorrhages and other retinal changes. 1 Marked activation of the renin-angiotensin system is often present and associated with the degree of microvascular damage. 3 Pressure-induced natriuresis contributes to contraction of blood volume and further activation of the renin-angiotensin system. 3
Case 30
A patient with blood pressure 185/115 mmHg and visual symptoms presents to the emergency department.
Question 30: What blood pressure threshold with visual symptoms indicates a hypertensive emergency requiring immediate intervention?
A. >140/90 mmHg
B. >160/100 mmHg
C. >180/120 mmHg
D. >220/130 mmHg
Answer: C
Explanation: Blood pressure >180/120 mmHg with visual symptoms indicates hypertensive emergency requiring immediate intervention. 1 Red flags indicating hypertensive emergency include blood pressure >180/120 mmHg with visual symptoms, bilateral flame-shaped hemorrhages on fundoscopy, associated symptoms, and papilledema. 1 This threshold with end-organ damage (visual symptoms) distinguishes hypertensive emergency from hypertensive urgency. 3 Immediate blood pressure reduction is indicated to limit extension or promote regression of acute hypertension-mediated organ damage. 3