Endgames Picture Quiz

Headache, flashing lights, and blurred vision

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h446 (Published 02 February 2015) Cite this as: BMJ 2015;350:h446
  1. Andrew Malem, specialist trainee year 2 ophthalmology,
  2. David Farnworth, consultant ophthalmologist
  1. 1Eye Department, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
  1. Correspondence to: A Malem andrew.malem{at}cantab.net

A 35 year old white man presented to eye casualty with a seven day history of severe headache, blurred vision, and flashing lights in both eyes. The severity of his headache was reported as 9/10, and he described it as spreading from his occipital region frontally. It was not worse on waking and he had no focal neurological signs. His medical history included chronic headaches since childhood, with frequent exacerbations of migraine, for which he took sumatriptan. He denied taking ergotamine. The current episode was characterised by the headache being more severe and the visual changes more prolonged than usual. He also had chronic back pain, for which he took daily paracetamol and codeine, was obese, and used continuous positive airways pressure for obstructive sleep apnoea.

Ophthalmic assessment showed visual acuities of 6/12 in both eyes, which corrected to 6/9 with pinhole. Intraocular pressure was 10 mm Hg (reference range 10-21) in both eyes and he had no relative afferent pupillary defect. His anterior segment examination was normal. His blood pressure was 165/117 mm Hg but he could not recall any previous blood pressure readings for comparison. Dilated fundoscopy showed abnormal changes in the posterior pole of both eyes (fig 1), which were largely symmetrical. Blood tests were sent for inflammatory markers and serology requested for possible infectious causes.

His general practitioner was contacted and ambulatory blood pressure monitoring set in place. No acute antihypertensive drugs were started. On review in clinic one week later, his blood pressure was 230/140 mm Hg.

Fig 1 Colour fundus photograph of the patient’s right eye at presentation

Questions

  • 1. What is the most likely underlying diagnosis?

  • 2. What abnormal retinal changes are seen?

  • 3. What is the grading classification for this condition?

  • 4. Does this patient need further investigations?

  • 5. How should this …

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