hypertensive retinopathy
TRANSCRIPT
HYPERTENSIVE RETINOPATHY
ANGEL DAS
Hypertensive Retinopathy
• Fundus changes that occur in patients with severe hypertension
• Clinical presentation includes changes of -Retinopathy -Choroidopathy -Optic neuropathy
pathogenesis
• 3 factors play role in pathogenesis1. Vasoconstriction2. Arteriosclerotic changes3. Increased vascular permeability
Pathophysiology
Systemic chronic
hypertensionArteriosclero
sis Narrowing of retinal arterioles
Retinal Ischaemia Hypoxia
Increased capillary
permeability
Focal Retinal Oedema, retinal haemorrhage,cotton wool
spots, hard exudates
Clinical types
Clinically hypertensive fundus changes can be described as• Chronic hypertensive retinopathy• Malignant/acute hypertensive retinopathy
Chronic hypertensive retinopathy
• Usually asypmtomatic• Clinical situations include
1.Hypertension with involutinary ( senile) sclerosis:elderly patients (> 50 yrs ),fundus changes comprise augmented
arteriosclerotic retinopathy.
2.Chronic hypertension with compensatory arteriolar sclerosis
• Seen in young individuals • young arterioles respond to HTN by prolifrative
and fibrous changes in media• In the kidneys there will be chronic
glomerulonephritis• so known as albuminuric or renal retinopathy
Normal Fundus
Fundus Changes
• Generalized arteriolar narrowing• Focal arteriolar narrowing• A-V nicking -hallmark of HR
• Salu’s sign – deflection of veins at A-V crossing• Bonnet sign – banking of veins distal to A-V crossing• Gunn sign – tapering of veins on either side of crossing
• Arteriolar Reflex Changes -bright, thin, linear reflex –Normal -diffuse, less bright reflex –Grade I/II -Copper wiring -Silver wiring
• Superficial retinal haemorrhages• Hard exudates• Cotton wool spots
Malignant hypertension
• rapid progression of the hypertensive state in a patient with relatively young arterioles undefended by sclerosis
• There will be retinopathy , choroidopathy & optic neuropathy
• It is asso. With renal insufficiency
Choroidopathy
• Elschnig’s spots- focal areas infarcted retinal pigment epithelium
• Siegrist streaks- due to fibrinoid necrosis in malignant hypertension
Grade I
Mild generalised arteriolar attenuation
Broadening of arteriolar light reflex
Vein concealment
Grading ( Keith & Wegner)
Grade II
Marked generalised narrowing and focal attenuation of artertioles
Salus’ Sign (deflection of veins at AV crossings)
Grade III
Copper wiring of arterioles
Bonnet Sign (banking of veins distal to av crossings)
Gunn Sign (tapering of vein on either side of av crossings)
Flame shaped haemorrhages,
Cotton wool spots Hard exudates
Gunn SignBonnet sign
Grade IV
Grade III changes
Silver wiring of arterioles
Papilloedema
• Scheie classification
ManagementMild HR BP control only
Moderate HR BP control +Assess cholesterol levels & if indicated cholesterol lowering agents
Accelerated HR Urgent anti hypertensive management by stepwise control of BP over a few hours
BP >160/100mm Hg- > 200/130mm Hg
Narrowing of nasal arterioles-generalised
Cotton wool spots; retinal hemmorhages- retinal hypoxia
‘Macular star’ – ‘flat macular detachment’
Retinopathy in PIH
Management
• Changes are reversible , disappear after delivery• In preorganic stage : conservative treatment , pregnancy
is continued under close observation• Advent of hypoxic retinopathy( cotton wool
spots,hemorrhages,retinal edema): indication for termination of pregnancy ,otherwise permanent visual loss or even loss of life may occur.