Intended for healthcare professionals

Endgames Spot Diagnosis

A bilateral macular star and optic disc oedema

BMJ 2016; 354 doi: (Published 21 September 2016) Cite this as: BMJ 2016;354:i4797
  1. Inês Leal1 2,
  2. David Cordeiro Sousa1 2
  1. 1Hospital de Santa Maria, Ophthalmology, Lisbon, Portugal
  2. 2Centro de Estudos das Ciências da Visão, Universidade de Lisboa, Lisbon, Portugal
  1. Correspondence to: I Leal ileal{at}

A 25 year old African man presented with reduced vision and headache lasting three hours. His blood pressure was 228/132 mm Hg (normal: <140/90 mm Hg1). Best corrected visual acuity was 20/80 in the right eye and 20/120 in the left eye (normal: 20/20). The figure shows the fundus of the right eye (fig 1).

Fig 1
Fig 1

Colour fundus photography of right eye, revealing retinal haemorrhages (purple arrow), cotton wool spots (yellow arrow), hard exudates forming a macular star (green arrow), and swelling of optic disc (blue arrow)

Based on the history and retinal findings, what is the diagnosis?


Hypertensive retinopathy due to malignant hypertension.


Bilateral fundoscopy revealed haemorrhages in all retinal quadrants, cotton wool spots, swelling of the optic disc, and hard exudates that had formed a “macular star.” This corresponds to exudation along the outer retinal layers, from where neuronal fibres exhibit a star shaped distribution. The differential diagnoses for these findings include radiation retinopathy, anaemia, blood dyscrasias, ocular ischaemic syndrome, and retinal vein occlusion. Exudation and haemorrhages may also be suggestive of bilateral neuroretinitis (idiopathic or infectious, such as cat scratch disease, Lyme disease, or syphilis).2 Acute management included systemic β blockers, nitrates, furosemide, and haemodialysis.3 Within five months, retinal changes slowly resolved and on six month follow-up best corrected visual acuity was 20/30 in both eyes.

Malignant hypertension may lead to ocular occlusive disease, such as ischaemic retinopathy, optic neuropathy, choroidopathy, and irreversible visual loss. When properly treated, lesions can be reversed and vision usually improves.2 3 Hypertensive retinopathy is a hallmark of malignant hypertension, an uncommon emergency that can be accompanied by ischaemic damage in kidney, heart, or brain.2 3 Its early detection is of paramount importance.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: none.

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent: Obtained.


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