hypertensive retinopathy dr ajay dudani dr yashesh maniar

HYPERTENSIVE RETINOPATHY

DR AJAY DUDANI

DR YASHESH MANIAR

-- MANY CAUSES

-- MAINLY ESSENTIAL HYPERTENSION

SYSTEMIC HYPERTENSION

(JNCV 5TH)

STATE OF PERSISTENT ELEVATED BLOOD PRESSURE ABOVE 140/90 mmHg.

5TH JOINT NATIONAL COMMITTEE CLASSIFICATION OF BLOOD PRESSURE

CATEGORY SYSTOLIC BP DIASTOLIC BP

(mmHg) (mmHg)

NORMAL <130 <85

HIGH NORMAL 130-139 85-89

STAGE 1 (MILD) 140-159 90-99

STAGE 2 (MOD.) 160-179 100-109

STAGE 3 (SEVERE) 180-209 110-119

STAGE 4(V. SEVERE) >210 >120

PATHOPHYSIOLOGICAL CHANGES IN HYPERTENSIVE OCULAR DISEASE

1. HYPERTENSIVE CHOROIDOPATHY

2. HYPERTENSIVE RETINOPATHY

-- VASOCONSTRICTIVE PHASE

-- SCLEROTIC PHASE

-- EXUDATIVE PHASE

-- COMPLICATIONS OF THE SCLEROTIC PHASE

3. HYPERTENSIVE OPTIC NEUROPATHY

-- OPTIC DISC EDEMA

-- OPTIC ATROPHY

-- ISCHEMIC OPTIC NEUROPATHY

OCULAR HYPERTENSIONOCULAR HYPERTENSION

ARTERIOSCLEROSIS

GRADE 0 NORMAL

GRADE 1 INCREASED LIGHT REFLEX, WITH MILD ARTERIOVENOUS CROSSING DEFECTS

GRADE 2 COPPER WIRE APPEARANCE

GRADE 3 SILVER WIRE APPEARANCE, WITH MARKED ARTERIO VENOUS CROSSING DEFECTS

GRADE 4 FIBROUS CORD

Grading of arteriolosclerosis

OCULAR HYPERTENSIONOCULAR HYPERTENSIONARTERIOLES

A-V RATIO FOCAL SPASM

GRADE 0 3:4 1:1

GRADE 1 1:2 1:1

GRADE 2 1:3 2:3

GRADE 3 1:4 1:3 +/- C W SPOT

GRADE 4 FIBROUS CORD NO DISTAL FLOW +/-ELS SPOT

HYPERTENSIVE HYPERTENSIVE RETINOPATHYRETINOPATHY

HEMORRHAGE EXUDATE DISC EDEMA

GRADE 0 - - -

GRADE 1 - - -

GRADE 2 - - -

GRADE 3 + + -

GRADE 4 + + +

GRADE 1 HTRGRADE 1 HTR

GENERALIZED GENERALIZED ARTERIOLAR ARTERIOLAR ATTENUATIONATTENUATION

BROADENING OF BROADENING OF ARTERIOLAR LIGHT ARTERIOLAR LIGHT REFLEXREFLEX

CONCEALMENT OF CONCEALMENT OF VEIN AT A-V VEIN AT A-V CROSSINGSCROSSINGS

GRADE 2 HTRGRADE 2 HTR

SEVERE SEVERE GENERALIZED GENERALIZED AND FOCAL AND FOCAL ARTERIOLAR ARTERIOLAR CONSTRICTIONCONSTRICTION

A-V CROSSING A-V CROSSING CHANGES (SALUS CHANGES (SALUS SIGN)SIGN)

GRADE 3 HTRGRADE 3 HTR

Copper wiring of arteriolesCopper wiring of arterioles Venous banking distal to A-Venous banking distal to A-

V crossing (bonnet’s sn)V crossing (bonnet’s sn) Venous tapering on either Venous tapering on either

side of crossing (gunn’s sn)side of crossing (gunn’s sn) Right angle deflection of Right angle deflection of

veins.veins. Flame shaped Flame shaped

hemorrhages cotton wool hemorrhages cotton wool spots, hard exudates.spots, hard exudates.

GRADE 4 HTRGRADE 4 HTR

All changes of All changes of grade 3grade 3

Silver wiring of Silver wiring of arteriolesarterioles

Disc edemaDisc edema

Ocular associations of Ocular associations of hypertensionhypertension

Retinal vein occlusion

• CRVO (Central Retinal Vein Occlusion)

• HRVO (Hemi Retinal Vein Occlusion)

• BRVO (Branch Retinal Vein Occlusion) Constitutes 69.5 % of all RVO cases

CRVO ...CRVO ...

Classic AppearanceClassic Appearance Mildest Form

CRVOCRVO

NON ISCHAEMIC ISCHAEMIC

62/F PR No 17474 CRVO62/F PR No 17474 CRVO

IVTAIVTA

(elsewhere)(elsewhere)

Baseline Baseline 20/50020/500

3 weeks 3 weeks 20/50020/500

3 months 3 months 20/20020/200

62/F PR No 17474 CRVO (S/P IVTA)62/F PR No 17474 CRVO (S/P IVTA)

2nd IVTA2nd IVTA

5 months 5 months 20/40020/400

8 months 8 months 20/10020/100

AvastiAvastinn

2nd Avastin2nd Avastin

Hayreh et al –Hayreh et al –

Non – Ischaemic : Due to simple occlusion of Non – Ischaemic : Due to simple occlusion of retinal venous systemretinal venous system

Ischaemic : Due to combined occlusion Ischaemic : Due to combined occlusion of of the arterial & venous circulationthe arterial & venous circulation

Green et al – Green et al – Thrombus formation in the region of lamina Thrombus formation in the region of lamina cribrosa is the primary eventcribrosa is the primary event

CRVO

Complications / Sequelae ...Complications / Sequelae ... Macular oedemaMacular oedema HaemorrhageHaemorrhage Ischaemia stimulates neovascularization inIschaemia stimulates neovascularization in

Optic discOptic disc RetinaRetina AngleAngle Iris - Rubeosis may cause Neovascular GlaucomaIris - Rubeosis may cause Neovascular Glaucoma

Rhegmatogenous RDRhegmatogenous RD Vascular complications Vascular complications

MicroaneurysymsMicroaneurysyms Optociliary vessels – collaterals between retinal & Optociliary vessels – collaterals between retinal &

ciliary vesselsciliary vessels

CRVO

Cilioretinal artery occlusion

Combined with CRVO

Cilioretinal artery occlusion

Combined with anterior ischaemic optic neuropathy

HRVO ...HRVO ...

HRVO ...HRVO ...

Superior & Inferior vein do not merge Superior & Inferior vein do not merge into Central Vein before entering into into Central Vein before entering into lamina cribrosalamina cribrosa

Like CRVO, only superior or inferior half Like CRVO, only superior or inferior half involvedinvolved

Types Types - 2/32/3rdrd :: Venous stasisVenous stasis- 1/31/3rdrd :: HaemorrhagicHaemorrhagic

Rest Rx or management same as CRVORest Rx or management same as CRVO

BRVO ...BRVO ...

45/M PR No 17422 BRVO45/M PR No 17422 BRVO

Baseline 20/500 STTBaseline 20/500 STT

3 weeks 20/500 Avastin3 weeks 20/500 Avastin

6 weeks/8 m 20/80 6 weeks/8 m 20/80

45/M PR No 17422 BRVO45/M PR No 17422 BRVO

BRVOBRVO

BRVO ...BRVO ...

Portion of retina involvedPortion of retina involved Mostly temporalMostly temporal

- - 62% Superotemporal62% Superotemporal- 38% Inferotemporal38% Inferotemporal

Nasal – uncommon & asymptomaticNasal – uncommon & asymptomatic Occurs exclusively at arterial Occurs exclusively at arterial

overcrossing at AV intersection by a overcrossing at AV intersection by a thrombusthrombus

Investigations in RVO ...Investigations in RVO ...

Hb/CBC/ESR/Platelet countHb/CBC/ESR/Platelet count BSL – Fasting/PPBSL – Fasting/PP BPBP Sr. Lipid ProfileSr. Lipid Profile IOP MeasurementIOP Measurement FFAFFA ANA/Anti-ds DNAANA/Anti-ds DNA VDRL/FTA-AbsVDRL/FTA-Abs LE CellLE Cell

In YoungIn Young ... ...

Protein C levelsProtein C levels

Protein S levelsProtein S levels

Platelet Analysis Platelet Analysis

Sr. & Urine for Homocysteine Sr. & Urine for Homocysteine

levelslevels

Others ...Others ...

Hb ElectrophoresisHb Electrophoresis

PT / PTTPT / PTT

Anti-Phospholipid antibodyAnti-Phospholipid antibody

Complete Cardiovascular Complete Cardiovascular

evaluationevaluation

Traditional Rx Options ...Traditional Rx Options ...

To treat the associated systemic diseases To treat the associated systemic diseases

(Medical Rx)(Medical Rx)

To treat the ocular complicationsTo treat the ocular complications

(Laser or Sx)(Laser or Sx)- - CRVO Study GroupCRVO Study Group

- BRVO Study Group- BRVO Study Group

Retinal artery Retinal artery macroaneurysmmacroaneurysm

Ocular associations of hypertension

Anterior ischaemic optic Anterior ischaemic optic neuropathyneuropathy

Ocular associations of hypertension

Ocular motor nerve palsies Ocular associations of hypertension