hypertensive retinopathy

HYPERTENSIVE RETINOPATHY

BY: Sana Saleem

Hypertensive Retinopathy

Definition IntroductionPrevalenceSymptomsPathophysiology Diagnostic techniques and signsAssociated conditionsManagement


Hypertensive retinopathy is damage to the retina caused by high blood pressure.

Hypertensive retinopathy is retinal vascular damage caused by hypertension.

Hypertensive retinopathy is a condition characterized by a spectrum of retinal vascular signs in people with elevated blood pressure

Hypertensive Retinopathy - Introduction

BilateralSymmetricalSmall blood vessel diseaseCaused by systemic hypertension

Acute or chronic Systolic or diastolic

Hypertensive Retinopathy – History & Symptoms

Possible history of systemic hypertensionSystemic hypertension largely

asymptomaticHypertensive retinopathy largely

asymptomaticThe eye examination will often give the

first clue of systemic hypertension

Hypertensive Retinopathy - Prevalence

The second most common retinal vascular disease

Systemic hypertension (>160/90mmHg) Malignant hypertension (240/140mmhg)

0.5-0.75%Hypertensive retinopathy 4-10%

Pathophysiology of Hypertensive Retinopathy

Primary response to hypertension is vasoconstriction

Vascular leakage Arterioscelrosis

involves thickening of the vessel wall.

Hypertensive Retinopathy – Pathophysiology

A disease of the retinal microvasculatureCholesterol deposition in the tunica intima

of medium and large arteries reduction in the lumen size of these vessels

Arteriolosclerosis causes a breakdown in autoregulation the high pressures in the arterioles are

transmitted to the retinal capillaries capillary closure or haemorrhage occurs

Fundoscopic Examination

Hypertensive retinopathy on fundoscopy is characterised by: arteriolar narrowing (graded 1 to 4

depending on the degree of narrowing); arteriolar venous nipping (constriction of

veins at crossing points); "cotton wool spots" on the retina (due to

ischaemic changes); flame haemorrhages or papilloedema.

Vascular Changes

Hypertensive Retinopathy – Prevalence, Risk factors

Afro-Caribbeans = relative risk factor 2xAgeFamily historyObesitySmokingStressAlcohol consumptionLack of exercise

Hypertensive Retinopathy – Diagnostic Techniques & Signs Ophthalmoscopy (non-malignant retinopathy)

Arteriosclerosis from chronic disease focal arteriolar narrowing arterio-venous crossing changes

• venous constriction and deflection• distal banking

arteriolar colour changes vessel sclerosis

Similar signs with ageing Sphygmomanometry

blood pressure measurement is required to make a positive diagnosis in the absence of malignant retinopathy changes

Hypertensive Retinopathy – Diagnostic Techniques & Signs

Generalised narrowing of the retinal arterioles


Tortuosity of the retinal arterioles not, in itself, a sign of hypertensive retinopathy segmental arteriolar tortuosity is such a sign

commonly found in the nasal retina Almost 80% of patients with hypertension do

not show tortuosity A standard 5 point grading scale can be used Record tortuosity type, severity and location


Early malignant Dot and blot

haemorrhages Hard and soft

exudates Diffuse arteriolar

narrowing Arterio-venous

crossing defects


Advanced malignant Macular star Pailloedema

Hypertensive Retinopathy - Classification

Grade DescriptionAlternative description

A:V ratio

Iminimal narrowing of the retinal arteries

Non-malignant

50%

IInarrowing of the retinal arteries in conjunction with regions of focal narrowing and arterio-venous nipping

Non-malignant

33%

IIIabnormalities seen in Grades I and II, as well as retinal haemorrhages, hard exudation, and cotton-wool spots

Malignant 25%

IVabnormalities encountered in Grades I through III, as well as swelling of the optic nerve head and macular star

Malignant <20%

Hypertensive Retinopathy – Classification Grade 2

Hypertensive Retinopathy – Classification

HR grades I and II are typically chronicHR grades III and IV are typically acute

diastolic blood pressure >= 110 correlates with grade III

diastolic blood pressure >= 130 correlates with grade IV

Hypertensive Retinopathy – Management

Appropriate treatment of the underlying hypertension If the patient is previously undiagnosed the patient needs

referral to their general practitioner for assessment A grade I or grade II hypertensive retinopathy

non-urgent referral A grade III hypertensive retinopathy

more urgent referral to the GP A grade IV hypertensive retinopathy

Px is in medical crisis. This patient needs immediate referral to a hospital eye casualty department

Hypertensive Retinopathy – Clinical Pearls


Diabetic Retinopathy

Dry retina:

few haemorrhages

rare oedema

rare exudate

multiple cotton wool spots

flame-shaped haemorrhages

visibly abnormal retinal arteries

Wet retina:

multiple haemorrhages

extensive oedema

multiple exudates

few cotton wool spots

rare flame-shaped haemorrhages

visibly abnormal retinal veins and capillaries

Ocular associations and complications of Hypertension

Retinal vein occlusionRetinal artery occlusionRetinal artery macroaneurysm Anterior ischemic optic neuropathy Ocular motor nerve palsy Uncontrolled Hypertension may adversely

affect diabetic retinopathy

Sickle-Cell Retinopathy

A condition characterized by dilation and tortuosity of retinal veins, microaneurysms, and retinal haemorrhages, with advanced cases manifesting neovascularisation, detachment of the retina, or vitreous haemorrhage.

Sickle cell retinopathy is a condition that can cause permanent damage to the eyes of a person with sickle cell disease. It is more commonly seen in patients with Hemoglobin SC type of sickle cell disease but can be found in any patient with sickle cell disease.

PATHOPHYSIOLOGY

Sickled red blood cells block the tiny blood vessels in the back of the eyes

Adaptive mechanism thinner blood vessels are formed to go around the blocked vessels.

These new vessels are often much weaker and can cause bleeding into the eye

Symptoms

What are the symptoms of sickle cell retinopathy?

Usually there are no symptoms in the early stages

Damage has already happened when vision problems occur.

Management

Peripheral Retinal Photocoagulation

Pars Plana Viterectomy: For traditional retinal detachment or persistent vitreous haemorrhage usually gives poor results

Source

Merck Sourcehttp://www.mercksource.com Merck Manual http://www.merck.com/mmpe/sec09/ch106/ch106f.html Clinical Ophthalmology -Kanski Medline Plus http://www.nlm.nih.gov/

The New England Journal Of Medicine http://content.nejm.org/cgi/content/short/351/22/2310

Eyeweb http://www.eyeweb.org/hypertension.htm University of Maryland Medical Center

http://www.umm.edu/ency/article/000999.htm

hypertensive retinopathy

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