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A 34-year-old woman presented with a short history of headache and blurred vision. Her corrected visual acuity was 20/30 and N24 in the left eye and 20/20 and N5 in the right; her blood pressure was 240/150 mm Hg. Funduscopic examination revealed grade IV hypertensive retinopathy, with widespread hemorrhages (Panel A, HEM), soft and hard exudates (SE, HE), and swelling of the optic disc (OD). Renal function was impaired, with a blood urea nitrogen concentration of 31 mg per deciliter (11.2 mmol per liter) and a serum creatinine concentration of 3.4 mg per deciliter (298 µmol per liter). Accelerated hypertension was diagnosed. The results of renal angiography, screening renal autoantibody, and urine metanephrine and normetanephrine concentrations were normal. Ten months later, after treatment with a combination of irbesartan, atenolol, and amlodipine, the patient's blood pressure was 110/70 mm Hg. Renal function was stable, with a creatinine concentration of 2.0 mg per deciliter (174 µmol per liter). Serial photographs of the retina demonstrated a progressive improvement in the hypertensive retinopathy (Panels B and C) after the successful treatment of the patient's elevated blood pressure.
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