A 29-year-old female presented with one day history of sudden onset painless loss of vision in both eyes. Loss of vision is associated with headache. known case of hypertension for 6 months on irregular. medication. Ocular Examination vision of the right eye was hand movement with no pinhole improvement, and on left eye it was counting finger 2 meter with no pin hole improvement. Intraocular pressure of right eye was 14 mmhg and left eye was 15 mmhg. Anterior segment examination of right eye was normal except relative afferent pupillary defect with no intraocular inflammation. anterior segment examination of left eye was normal. Distant direct ophthalmoscopy found that both eyes media hazy and greyish reflex. Indirect ophthalmoscopy showed - Bilateral disc swelling with inferior retinal detachment extending 4 to 7 clock hours with flame shaped haemorrhages and cotton wool spots over blood vessels with AV crossings with dull foveal reflex. No retinal tears were observed in the peripheral retina examination with scleral depression. OCT showed bilateral exudative detachment of sensory retina. A systemic work up was conducted and found to be blood pressure was 200/120 mmhg. Patient was referred to physician for management of hypertension. Physician diagnosed that the patient has acute renal failure with laboratory investigation of urea 101mg/dl and creatinine-11.6mg/dl, requiring urgent dialysis. Patient underwent dialysis. On follow up after 1 month blood pressure was with in normal limits. Visual acquity improved to 6/18 Both eyes. Dilated fundus examination demonstared a significant resolution of the exudative retinal detachment except with few residual haemorrhages.

The potential causes of serous retinal detachment include a variety of conditions that can be classified into idiopathic, congenital, postsurgical, inflammatory, uveitic, hematologic, vascular, and neoplastic 8. A complete examination, anamnesis and workup should be undertaken in patients with serous retinal detachment. The main differential diagnostic possibility in the case we reported was the Vogt- Koyanagi-Harada syndrome, a systemic inflammatory disease with ocular, neurological and skin involvement, caused by an immune reaction to antigens of melanic cells 7, 9. It usually affects young women. Its hallmark is the presence of lobulated bilateral serous retinal detachment involving the macula, and associated with variable degrees of vitreous cells and flare. The absence of extraocular manifestations, altogether with the absence of increased vitreal cellularity, made us rule out this possibility 10. Hypertension can cause ischemic changes due to a disruption of the external blood-retinal barrier 7. These changes can be explained by the increase of endogenous vasoconstrictor agents, leading to vasoconstriction and fibrinoid necrosis of the choroidal vessels 5. This leads to ischemia of the overlying retinal pigment epithelium (Elschnig spots) 11. Ischemia of the pigment epithelium allows leakage into the subretinal space (serous retinal detachment) 12. In our case, the serous retinal detachment resolved following a normalization of blood pressure. Fundus findings were suggestive of hypertensive retinopathy such as splinter hemorrhages, vascular sclerosis and tortuosity. Cases of hypertensive retinopathy with serous retinal detachment have been previously reported and are related to malignant hypertension, preeclampsia, eclampsia, hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome during pregnancy, primary pulmonary hypertension, and in Castleman’s disease 9. In these cases, the subretinal exudation was typically limited to the macular area without any massive serous bilateral detachment.

However, there are a few isolated case reports in literature where exudative retinal detachment is a presenting feature. Malhotra et al.13 described similar presenting features in a young female with with bilateral renal artery stenosis. Pierro L et al. 14 de Venecia G et al. 15 reported a case of exudative retinal detachment in previously diagnosed case of renovascular hypertension. But in our case the patient presented with bilateral exudative retinal detachment which led to the diagnosis of acute kidney injury with secondary hypertension within few days.. In this scenario we are emphasizing here the role of the ophthalmologist in first detecting a case of secondary hypertension and quick management of the patient's complaints. It is also clearly demonstrated that ophthalmic manifestations do not need any specific treatment other than controlling blood pressure. Good comprehensive examination of the patient can lead to a systemic diagnosis and control of systemic parameters will help in improving associated ophthalmic features

In conclusion, our case indicates that accelerated hypertension may precipitate massive spontaneous bilateral exudative retinal detachment It is necessary to obtain a fundus examination in any patient with elevated blood pressure and concomitant vision complaints. Therefore, screening hypertensive patients involves close collaboration between internist and ophthalmologist. Antihypertensive is the first line of treatment, but if the exudative retinal detachment is not resolved and retinal detachment is chronic and bullous, surgical intervention to drain the fluid can be planned 16. Accelerated HTN may precipitate bilateral exudative retinal detachment 17. Bilateral exudative retinal detachment is a catostropic event which results in devastating vision loss within very short time span. Timely intervention may save the vision loss and renal failure.