The great masquerader!

A 10-year-old girl presented with diminution of vision in both eyes and headaches for the last 1 month. The patient had no known systemic illness and was not on any systemic medication. Her best corrected visual acuity in both eyes was 20/800, and intraocular pressure in both eyes was 16 mmHg. The fundus of both eyes revealed optic disc edema, extensive hard exudates, and subretinal fluid around the posterior pole along with arteriolar attenuation [Fig. 1a and b]. Her blood pressure was 240/160 mmHg.Figure 1: (a, right eye) and (b, left eye) reveals optic disc edema, marked arteriorlar attenuation, tortuous vessels, multiple dense hard exudates and cotton wool spots, flame shaped hemorrages, and subretinal fluid around posterior pole (c, right eye) and (d, left eye) shows widefield images in addition to previous findings revealing multiple Elschning spots (blue arrowhead) in mid-peripheryWhat Would be Your Next Step? Emergency referral for hypertension followed by systemic workup OCT Fundus autofluorescence Fluorescein angiography. Findings Fig. 1 (a, right eye) and (b, left eye) reveals optic disc edema, marked arteriolar attenuation, tortuous vessels, multiple dense hard exudates and cotton wool spots, flame-shaped hemorrhages, and subretinal fluid around the posterior pole. Wide-field images [Fig. 1c and d] in addition revealed multiple Elschning spots (blue arrowhead) in mid-periphery. Diagnosis Malignant hypertensive retinopathy. Correct Answer (A) Emergency referral for hypertension followed by systemic workup. Fundus picture of severe hypertensive retinopathy with papillopathy and choroidopathy with a blood pressure of 240/160 mmHg in a 10-year-old patient warranted a thorough systemic workup by a pediatrician after systemic stabilization. The patient was diagnosed with phaeochromocytoma. When diagnosed in its early stages, phaeochromocytoma can result in reversible damage and lead to a good visual recovery. This case also highlights the occurrence of all hypertensive changes in the posterior segment due to a severe and persistent rise in blood pressure. Discussion Hypertensive retinopathy is a condition characterized by vascular changes in the retina in the event of increased blood pressure Although mostly the changes are seen in the retina, there can be involvement of the choroid and optic nerve as well.[1] There can be primary and secondary hypertension. Pheochromocytoma is a cause of secondary hypertension and is a rare tumor arising in chromaffin cells of the adrenal medulla or paraganglia. Clinical features are mainly due to the constriction of vessels by the circulating catecholamines and the obstruction of arterioles, leading to the disruption of the blood-retina barrier.[2] Visual prognosis is generally good, especially in milder cases. Vision loss may result from prolonged papilledema or retinal pigment changes due to serous retinal detachment.[3] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.