Occasionally,patients with a severe hypertensive problem present directly to the ophthalmologist because their main symptom is blurring of the vision, the other more usual symptoms being less evident. On examination, the visual acuity might be only slightly reduced unless there is significant macular oedema and there might be some enlargement of the blind spot and constriction of the visual fields. Inspection of the fundus reveals marked swelling of the optic disc, the oedema often extending well away from the disc with scattered flame-shaped haemorrhages. If the diastolic blood pressure is above 110-120mmHg, there is little doubt about the diagnosis, but below this level it is essential to bear in mind the possibility of raised intracranial pressure from other causes. When hypertension is as severe as this, the patient should be treated as an acute medical emergency and referred without delay to the appropriate physician.
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