Elschnig Spots (Choroidal Infarcts): Hypertension Sign

Elschnig spots are focal choroidal infarcts that appear in severe or accelerated hypertension.

They mark ischemia of the choriocapillaris and the overlying retinal pigment epithelium (RPE).

Because they follow a sharp rise in blood pressure, they also carry systemic weight.

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What Elschnig Spots Are

Each spot represents a lobule of choriocapillaris that has lost its blood supply.

The RPE above that lobule then becomes ischemic and necrotic.

As a result, the lesion lies deep to the retina, at the level of the RPE.

Why the Choroid Fails

Choroidal vessels lack the autoregulation that protects retinal arterioles.

Instead, sympathetic tone largely controls choroidal flow, so a pressure surge triggers intense vasoconstriction.

Fibrinoid necrosis and thrombosis of choroidal arterioles may then occlude the choriocapillaris.

Hayreh and colleagues described this sequence in experimental malignant hypertension in monkeys.

Who Develops Elschnig Spots

Choroidopathy tends to appear when blood pressure rises abruptly, often in younger patients.

Sclerotic vessels in long-standing hypertension may partly shield the choroid.

• Malignant hypertension
• Preeclampsia, eclampsia and HELLP syndrome
• Acute renal disease, including scleroderma renal crisis
• Pheochromocytoma
• Thrombotic thrombocytopenic purpura and disseminated intravascular coagulation

Acute Elschnig Spots on Examination

Acute lesions look like small, round, yellow or gray-white patches deep to the retina.

They often cluster in the posterior pole and midperiphery.

Overlying retinal vessels cross them without interruption, which confirms their deep location.

In addition, numerous acute spots may accompany serous retinal detachment.

Healed Elschnig Spots

Over several weeks, the acute lesion evolves into a pigmented scar.

The classic healed spot shows a dark pigment clump surrounded by a pale, depigmented halo.

Therefore, healed spots record a past hypertensive crisis even when current pressure is normal.

Elschnig Spots on Fluorescein Angiography

In the early phase, acute spots appear hypofluorescent because the affected choriocapillaris does not fill.

Later, the lesions stain and may leak as the damaged RPE loses its barrier function.

Healed spots behave differently.

Their pigmented centers block fluorescence, while the atrophic rim shows a window defect.

OCT and ICG Findings

On OCT, acute lesions show hyperreflective changes at the RPE and outer retina, sometimes with subretinal fluid.

Healed spots then show RPE irregularity and outer retinal thinning.

Also, indocyanine green angiography can reveal choroidal hypoperfusion beyond the visible spots.

Siegrist Streaks and Elschnig Spots

Siegrist streaks are linear chains of pigment along sclerosed choroidal arteries.

They also signal severe hypertensive choroidopathy, and both signs may coexist in one fundus.

Hypertensive Serous Detachment

Choroidal ischemia damages the RPE pump and the outer blood retinal barrier.

As a result, bullous subretinal fluid can mimic central serous chorioretinopathy.

However, this fluid typically resolves once blood pressure falls.

What Elschnig Spots Imply About Blood Pressure

Acute spots point to a hypertensive emergency until proven otherwise.

Many such eyes also show flame hemorrhages, cotton wool spots, macular star or disc edema.

Therefore, the patient needs same-day blood pressure measurement and urgent medical assessment.

Healed spots, by contrast, call for review of current control and end-organ status.

Differential Diagnosis in Elschnig Spots

• APMPPE, with placoid lesions and early hypofluorescence
• Serpiginous choroiditis and multifocal choroiditis scars
• Healed toxoplasmosis or histoplasmosis scars
• Pigmented RPE scars after trauma or laser

Blood pressure and pregnancy status usually settle the question.

Workup for Patients With Elschnig Spots

First, measure blood pressure before the patient leaves the clinic.

Then refer urgently to the emergency department when readings are severely raised.

Physicians typically check renal function, urinalysis, blood count and, in pregnancy, liver enzymes and platelets.

Young patients also warrant screening for secondary causes of hypertension.

Treatment and Its Limits

No ocular treatment reverses a choroidal infarct.

Instead, physicians lower blood pressure in a controlled way, because an abrupt fall risks optic nerve ischemia.

Delivery usually resolves the choroidopathy of preeclampsia.

Serous detachment then settles, while established RPE scars remain.

Visual Prognosis in Elschnig Spots

Vision often recovers well when spots spare the fovea.

However, macular RPE damage can leave permanent metamorphopsia or reduced acuity.

Explain that the scars are stable and reflect systemic risk, so treatment adherence matters.

Finally, review the fundus with photographs and OCT a few weeks after pressure control.

Pitfalls to Avoid

• Do not label healed spots as old chorioretinitis without asking about hypertension or pregnancy
• Never send a patient with acute spots home without a blood pressure reading
• Avoid diagnosing central serous chorioretinopathy before checking blood pressure
• Remember that a normal current reading does not exclude a past crisis

For the latest studies, see the PubMed results for elschnig spots.

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References

1. Hayreh SS, Servais GE, Virdi PS. Fundus lesions in malignant hypertension. VI. Hypertensive choroidopathy. Ophthalmology. 1986;93:1383-1400.
2. Tso MO, Jampol LM. Pathophysiology of hypertensive retinopathy. Ophthalmology. 1982;89:1132-1145.
3. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004;351:2310-2317.
4. Bowling B. Kanski’s Clinical Ophthalmology: A Systematic Approach. 8th ed. Elsevier; 2016.
5. American Academy of Ophthalmology. Basic and Clinical Science Course, Section 12: Retina and Vitreous. San Francisco: AAO.
6. Whelton PK, Carey RM, Aronow WS, et al. 2017 guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension. 2018;71:e13-e115.