Neglected Total Rhegmatogenous Retinal Detachment with Proliferative Vitreoretinopathy Coexisting with Bilateral Grade IV Hypertensive Retinopathy in Severe Pre-eclampsia: A Case Report from an Indonesian Archipelagic Province

Abstract

Background: Pre-eclampsia injures the eye through the same endothelial mechanism that injures the kidney and brain, and its retinal signs track systemic severity. Rhegmatogenous retinal detachment arises by an entirely different mechanism, yet where vitreoretinal care is distant the two may present together in one patient, a coexistence not previously described.

Objective: To describe a previously unreported coexistence of chronic rhegmatogenous retinal detachment and grade IV hypertensive retinopathy of severe pre-eclampsia in one patient, and to set out the structural features that distinguish the two mechanisms at the bedside — the distinction that determines whether treatment is medical or surgical.

Case presentation: A 36-year-old woman was examined three weeks after a term vaginal delivery, four months after sudden visual loss in the left eye that began in the fifth month of a pregnancy complicated by pre-eclampsia. She also reported 19 years of unassessed visual loss in the right eye. Blood pressure was 154/114 mmHg. Acuity was hand movement right and 0.1 decimal left. The right eye showed total retinal detachment with a break at 9 o'clock, fixed folds, pigment clumping, grade C posterior proliferative vitreoretinopathy, posterior subcapsular cataract and a 7-degree sensory exotropia; the left eye showed optic disc swelling, peripapillary haemorrhage and a macular star. Both eyes met Scheie grade IV. Left macular tomography gave a central subfield of 182 micrometres and a minimum foveal thickness of 98, with five of nine sectors below the first percentile. No relative afferent pupillary defect was detectable.

Conclusion: Chronic rhegmatogenous and hypertensive retinal disease can coexist in one patient and must be separated structurally, because only one responds to blood pressure control. Sub-percentile macular thinning tempers the expectation of full recovery, and bilateral disease can abolish the relative afferent pupillary defect that would otherwise flag a blind eye.