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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 434-436

Malignant hypertension in a child - What lies beneath?

1 Paediatric Ophthalmology Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
2 Neuro Ophthalmology Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
3 Department of Retina and Vitreous services, Aravind Eye Hospital, Madurai, Tamil Nadu, India

Date of Submission02-Jul-2021
Date of Acceptance27-Nov-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Marushka Aguiar
Department of Paediatric Ophthalmology, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai - 625 020, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1746_21

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We report a case of a 7-year-old girl presenting to the Neuro-Ophthalmology OPD with only complaints of chronic headache who was found to have malignant (grade 4) hypertensive retinopathy. Visual acuity was 20/400 in the right eye and 20/80 in the left eye. Blood pressure was 220/120 mm Hg. The patient was not a known hypertensive. Fundoscopy revealed bilateral optic disc swelling, macular stars, and serous retinal detachment in both eyes. The patient was urgently referred to pediatrician for detailed evaluation and systemic control of hypertension. This emphasizes the need for checking blood pressure in children presenting with chronic headache.

Keywords: Blood pressure, hypertensive retinopathy, pediatric

How to cite this article:
Aguiar M, Kumar S M, Shetty S, Rajan RP. Malignant hypertension in a child - What lies beneath?. Indian J Ophthalmol Case Rep 2022;2:434-6

How to cite this URL:
Aguiar M, Kumar S M, Shetty S, Rajan RP. Malignant hypertension in a child - What lies beneath?. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 18];2:434-6. Available from: https://www.ijoreports.in/text.asp?2022/2/2/434/342897

Hypertensive retinopathy is rare in children and infants and is mostly only detected in children who are referred to ophthalmologists with known hypertension on treatment. The estimate of hypertension in children is 3.2%–3.5%.[1] Secondary rather than primary hypertension is more common in children. Untreated hypertension usually leads to end-organ damage due to micro and macroangiopathy.[2] The clinical presentation may vary from asymptomatic patients to hypertensive crisis. While older children may present with headaches, visual obscuration, dizziness, and nausea, younger children tend to present with altered behavior, lethargy, and irritability.[1],[3] We present a unique case of grade 4 hypertensive retinopathy in a young child with no visual complaints, referred incidentally for evaluation of headache.

  Case Report Top

We report a case of a 7-year-old girl who presented to the Neuro-Ophthalmology department of our hospital with a history of persistent headache for a year. The child had been examined by another doctor who had advised MRI brain which showed a few areas of focal cerebritis and was sent for a detailed ophthalmological examination. The child's BMI was normal for age, and she had no known systemic disease.

On ophthalmic examination, her visual acuity was 20/400 in the right eye and 20/80 in the left eye. There was a relative afferent pupillary defect in the right eye. Her ocular movements were full range. Due to poor vision, we were not able to test color vision in her right eye, but her left eye color vision was normal. The rest of the anterior segment examination was unremarkable.

On fundoscopy, there was evidence of bilateral optic disc swelling, vascular leakage (macular star), and secondary serous retinal detachment with drusenoid type of detachment of the retinal pigment epithelium in both eyes. This clinical appearance is consistent with malignant (grade 4) hypertensive retinopathy [Figure 1],[Figure 2],[Figure 3],[Figure 4].
Figure 1: Fundus photograph of the right eye showing severe disc edema with macular star

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Figure 2: Fundus photograph of the left eye showing severe disc edema with macular star

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Figure 3: OCT left eye

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Figure 4: OCT right eye

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The child's blood pressure was checked and was found to be persistently high (220/120 mm Hg). The normal cut-off for children is taken as more than or equal to 130/80 mm Hg.[4] The parents denied any history of the child being hypertensive or being treated with any medications. She was being treated symptomatically with analgesics for her chronic headache. Surprisingly, she did not complain of defective vision before. The child was urgently referred to a pediatrician for detailed evaluation and systemic control of hypertension. Guarded visual prognosis was clearly explained to the parents due to the chronicity of the condition. The patient was detected to have unilateral renal artery stenosis and was referred to a pediatric nephrologist for further management. When the child followed up, the BP was controlled but the fundus findings unfortunately remained the same and hence there was no improvement in the child's vision.

  Discussion Top

Malignant hypertension causing grade 4 hypertensive retinopathy in the pediatric population has been rarely reported.[5],[6] We were able to find only two such cases reported in the literature. In a previously reported case series of children with hypertension, the prevalence of retinopathy was 6%–51%,[1],[2],[3] and the severity was reported as mild in the majority of cases.

Hypertensive crisis in children is an urgent condition requiring immediate accurate diagnosis and proper treatment to prevent organ damage and even death of the patient.

It is very important to detect hypertension in children as we usually tend to think of hypertension mostly being a disease of older adults and do not always check BP in children presenting to us for an ophthalmological evaluation with complaints of headache.

Such a case acts as an eye-opener because we see that this child never complained of defective vision even though her vision was so poor. As such, many parents would never consider visiting an ophthalmologist. If hypertension is diagnosed too late, the risk of permanent visual impairment due to hypertensive retinopathy and macular involvement is much higher as was seen in our case and is an important cause of pediatric visual impairment.

If hypertension and underlying disease would have been detected earlier, we could have probably saved this child's vision.

If hypertension is diagnosed too late, there is an increased risk of permanent visual impairment due to hypertensive retinopathy.

  Conclusion Top

Our case report stresses the importance of routine measurement of blood pressure in children as well as how serious the consequences of undetected and untreated hypertension can be. As pediatric ophthalmologists, we should make it a practice to check the BP of our patients at least once a year and more regularly if they are known hypertensives.

Such children need a comprehensive coordinated evaluation by an ophthalmologist, a pediatrician, and a nephrologist. This will help us not only to save the vision of the child but more importantly to diagnose the underlying cause of hypertension in such children which will ultimately be life-saving.

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


Conflicts of interest

There are no conflicts of interest.[6]

  References Top

Foster BJ, Ali H, Mamber S, Polomeno RC, MacKie AS. Prevalence and severity of hypertensive retinopathy in children. Clin Pediatr 2009;48:92630.  Back to cited text no. 1
Daniels SR, Lipman MJ, Burke MJ, Loggie MJH. Determinants of retinal vascular abnormalities in children and adolescents with essential hypertension. J Hum Hypertens 1993;7:23-8.  Back to cited text no. 2
Krause I, Snir M, Cleper R, Fraser A, Kovalski Y, Axer Siegel R, et al. Ocular complications in children and adolescents following renal transplantation. Pediatric Transplant 2010;14:77-81.  Back to cited text no. 3
Di Bonito P, Di Sessa A. New diagnostic criteria for hypertension in children and adolescents: Lights and shadows. Children (Basel) 2020;7:196.  Back to cited text no. 4
Tibbetts MD, Wise R, Forbes B, Hedrick HL, Levin AV. Hypertensive retinopathy in a child caused by pheochromocytoma: identification after a failed school vision screening. J AAPOS 2012;16:97-9. doi: 10.1016/j.jaapos.2011.09.010. Epub 2012 Jan 14. PMID: 22245022.  Back to cited text no. 5
Chahal HS, Much JW, Newman SA, Ghazi NG. Hypertensive retinopathy in a child. Br J Ophthalmol 2011;95:741; quiz 755-6. doi: 10.1136/bjo.2009.164053. PMID: 20693485.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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