International Journal of Retina (IJRETINA) 2025. Volume 8. Number 2. P-ISSN. E-ISSN. HYPERTENSIVE OPTIC NEUROPATHY AS A PRESENTATION OF SYSTEMIC LUPUS ERYTHEMATOSUS: A CASE REPORT Lia Meuthia Zaini1. Putri Nabillah Mulya2 Vitreoretinal Division. Ophthalmology Department. Zainoel Abidin Hospital. Faculty of Medicine. Universitas Syiah Kuala. Banda Aceh. Indonesia Medical Intern. Ophthalmology Department. Zainoel Abidin Hospital. Faculty of Medicine. Universitas Syiah Kuala. Banda Aceh. Indonesia Abstract Introduction: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting multiple organ systems, including the eyes. Hypertensive optic neuropathy is a rare but serious manifestation of SLE that may precede SLE diagnosis. This case highlights the early ocular involvement in a young patient with undiagnosed SLE. Case Report: A 21-year-old female presented to our ophthalmology clinic with blurry vision in both eyes, along with elevated blood pressure at 165/126 mmHg. Ophthalmic examination revealed visual acuity of 20/200 on both eyes, bilateral optic disc swelling, macular edema, flame-shaped hemorrhages, and cotton-wool spots. These findings were consistent with hypertensive optic The antihypertensive drugs were initiated and planned for intravitreal bevacizumab The patient was referred to internal medicine. Laboratory tests and clinical findings indicated secondary hypertension, anemia, leukopenia, and thrombocytopenia. Immunoserological testing confirmed a diagnosis of SLE. The patient was initiated on systemic immunosuppressive therapy. Eight weeks after the first visit, she showed significant improvement, with the resolution of macular edema and optic disc swelling. The patientAos visual acuity improved to 20/50 in the right eye (RE) and 20/20 in the left eye (LE). Discussion: Hypertension in SLE is multifactorial, involving endothelial dysfunction, kidney injury, immune activation, and autoantibodies. Hypertensive retinopathy progresses through three phases: vasoconstrictive, sclerotic, and exudative, characterized by arterial narrowing, structural vascular changes, and blood-retina barrier disruption, leading to macular edema and ischemia. Diagnosis is based on fundoscopic examination and Optical Coherence Tomography (OCT), while management focuses on blood pressure control, anti-VEGF therapy, and close monitoring to prevent further complications. Conclusion: Early detection and multidisciplinary management are crucial in preventing irreversible visual loss and systemic complications. Regular ophthalmic follow-up and blood pressure monitoring are essential in SLE management. Keywords: hypertensive optic neuropathy, hypertensive retinopathy, macular edema, lupus nephritis, systemic lupus erythematosus, anti-VEGF Cite This Article: ZAINI. Lia Meuthia. MULYA. Putri Nabillah. HYPERTENSIVE OPTIC NEUROPATHY PRESENTATION SYSTEMIC LUPUS ERYTHEMATOSUS. International Journal of Retina, [S. ], v. 8, n. 2, sep. ISSN 2614-8536. Available at: . Date accessed: 30 sep. doi: https://doi. org/10. 35479/ijretina. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. INTRODUCTION Systemic Correspondence to: Lia Meuthia Zaini, (SLE) is a chronic Zainoel Abidin Hospital. Faculty of Medicine. Universitas Syiah Kuala. Banda Aceh. Indonesia, disease driven by liameuthiazaini@gmail. can impact nearly every organ in the body. Its clinical manifestations are diverse, involving the skin, kidneys, musculoskeletal, and nervous systems. Ocular involvement can affect the external eye, the anterior segment, the retina, the choroid, or neuro-ophthalmological These ocular manifestations are not included in the diagnostic criteria established by European League Against Rheumatism/American College of Rheumatology (EULAR/ACR). 1 However, severe complications are relatively common, and treatment becomes significantly more challenging or less effective once ocular involvement progresses to advanced stages. Therefore, periodic ophthalmological reviews are recommended in all patients with lupus. Among ocular manifestations, retinal changes are particularly common and are often used as clinical indicators of disease activity. 3 Retinopathy in SLE can be caused either as a direct consequence of SLE-related inflammation or as a secondary complication, such as lupus nephritis-induced The prevalence of retinopathy ranges from 3% in well-controlled patients to 29% in those with more active systemic disease. 4 Here, we report a case of hypertensive optic neuropathy presented to our ophthalmology clinic before the diagnosis of SLE. This highlights the importance of early detection and management of hypertensive complications in SLE, as they can significantly impact visual prognosis. persistent headaches, myalgia, hair loss, and rashes on her ears for the past three weeks. She had a history of wearing spectacles with a prescription of 5 diopters in both eyes. Neither the patient nor her family had a history of autoimmune disease. There was no history of recent medication use. initial examination, her blood pressure was elevated at 165/126 mmHg, with a heart rate of 89 beats per minute and a respiratory rate of 22 breaths per minute. The remainder of her systemic Ophthalmological evaluation revealed a visual acuity of 20/200 in the RE and the LE. Intraocular pressure was within normal limits. A dilated fundus examination (Figure . revealed bilateral optic disc swelling, with a cup-to-disc ratio of 0. 3 in both eyes. The macula appeared elevated, with no foveal reflex surrounded by exudates with star Optical coherence tomography (OCT) (Figure . showed increased central macular Numerous flame-shaped hemorrhages and cotton-wool spots were observed. A diagnosis of hypertensive optic neuropathy was made, and Intravitreal bevacizumab was recommended for both eyes to treat macular edema. Based on her symptoms and physical findings, the patient was referred to the internal medicine department for further evaluation of the underlying cause of hypertension. Laboratory tests, as shown in Table 1, revealed hemoglobin: 10. 2 g/dL, white blood cells: 3,390/mmA. CASE REPORT A 21-year-old Acehnese female presented to our ophthalmology clinic with complaints of bilateral blurry vision since the previous day. There were no other ophthalmic symptoms, such as scotoma, red eye, pain, diplopia, proptosis, or Additionally, the patient reported Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. platelet count: 94,000/mmA, elevated D-dimer at 2,140 ng/mL, low HDL at 37 mg/dL, and elevated LDL at 124 mg/dL. Kidney function tests were normal, and the renal ultrasound was She was treated with nifedipine 30mg, bisoprolol 5mg, and rivaroxaban 10mg once While undergoing regular follow-up at the ophthalmology and internal medicine clinics, the patient developed anemia three weeks later, with a hemoglobin level of 8 mg/dL and was hospitalized for further management. She received a packed red cell transfusion and was started on intravenous furosemide 40 mg and methylprednisolone 125 mg, followed by oral methylprednisolone 8 mg three times daily, spironolactone 25 mg twice daily, and terazosin 2 mg once daily. Further workup was done, including an antinuclear antibodies (ANA) profile test and urinalysis. Immuno-serological tests showed high anti-double-stranded DNA levels . 9 IU/mL) and a positive antinuclear antibody double-stranded DNA, nucleosomes, histones, and ribosomal protein. Complement and antiphospholipid antibody tests were not performed. Urinalysis showed positive leukocytes, protein, and granular and hyaline casts. These findings confirmed the diagnosis of systemic lupus erythematosus with lupus nephritis. The patient was treated with methylprednisolone, calcium carbonate, clopidogrel, furosemide, terazosin, and valsartan. Figure 1. Fundus photograph of the patient at the initial presentation. Optic disc edema . lack arro. Macular edema with AostarAo exudate configuration . hite arro. Retinal hemorrhages . lue arro. Cotton-wool spots . reen arro. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. Figure 2. Optical Coherence Tomography of the patient at the initial presentation. Increased central macular thickness associated with subretinal fluid and exudation . hite arro. Table 1. Laboratory Findings Laboratory Results Reference Range Hematology Hemoglobin 10,2 g/dL 12,0-15,0 g/dL Hematochrits 37-47 % Leukocytes 3,39 x 103/mm3 4,5-10,5 x 103/mm3 Thrombocytes 94 x 10 /mm 150-450 x 103/mm3 Ureum 25 mg/dL 13-43 mg/dL Creatinine 0,86 mg/dL 0,51-0,95 mg/dL Erythrocytes Sedimentation Rate 12 mm/hour <20 mm/hour C-Reactive Protein Rheumatoid Factor D-dimer 2140 ng/mL <500 ng/mL Urinalysis Leukocytes Erythrocytes Epithelial Cells Protein positive ( . Keton Granular Cast Hyaline Bacteria Immunoserology Anti-double-stranded DNA 512,9 IU/mL <100 IU/mL Nucleosome (NUC) Histones (HI) Ribosomal Protein (RIB) Control (K. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. Figure 3. Eight-week follow-up after the first visit. The papilledema and retinal hemorrhages had resolved, leaving a star-shaped exudate. Figure 4. Optical Coherence Tomography of the patient after the administration of intravitreal bevacizumab. Reduction in central macular thickness. At the eight-week follow-up after the first visit, the patient showed significant improvement. The papilledema had resolved, leaving star-shaped exudates, as shown in Figure 3. The macular edema had also resolved, as confirmed by OCT, which demonstrated a reduction in central macular thickness, as shown in Figure 4. Fundus examination revealed a marked reduction in optic disc swelling, with the resolution of flame-shaped hemorrhages and cotton-wool spots. The macular contour appeared more defined, and the foveal reflex was restored. The patient also reported subjective improvement in visual acuity. Visual acuity after therapy showed improvement to 20/50 in the right eye and 20/20 in the left eye. Blood antihypertensive therapy, and systemic lupus erythematosus treatment was continued under the supervision of the internal medicine department. Regular follow-up was scheduled to monitor disease progression and prevent recurrence. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. DISCUSSION