Communication, Comfort Zone Key to Managing Hypertensive Emergencies

I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?

Dennis Swanson, MD

Grand Rapids, Mich.

Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.

Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.

It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH