HYPERTENSIVE RETINOPATHY DR AJAY DUDANI DR YASHESH MANIAR

-- MANY CAUSES -- MAINLY ESSENTIAL HYPERTENSION

SYSTEMIC HYPERTENSION (JNCV 5 TH ) STATE OF PERSISTENT ELEVATED BLOOD PRESSURE ABOVE 140/90 mmHg.

5 TH JOINT NATIONAL COMMITTEE CLASSIFICATION OF BLOOD PRESSURE CATEGORYSYSTOLIC BPDIASTOLIC BP (mmHg) (mmHg) NORMAL<130<85 HIGH NORMAL STAGE 1 (MILD) STAGE 2 (MOD.) STAGE 3 (SEVERE) 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 HYPERTENSION OCULAR HYPERTENSION ARTERIOSCLEROSIS GRADE 0NORMAL GRADE 1INCREASED LIGHT REFLEX, WITH MILD ARTERIOVENOUS CROSSING DEFECTS GRADE 2 COPPER WIRE APPEARANCE GRADE 3SILVER WIRE APPEARANCE, WITH MARKED ARTERIO VENOUS CROSSING DEFECTS GRADE 4 FIBROUS CORD

Grading of arteriolosclerosis

OCULAR HYPERTENSION ARTERIOLES A-V RATIOFOCAL SPASM GRADE 03:41:1 GRADE 11:21:1 GRADE 2 1:32:3 GRADE 31:41:3 +/- C W SPOT GRADE 4 FIBROUS CORDNO DISTAL FLOW +/-ELS SPOT

HYPERTENSIVE RETINOPATHY HEMORRHAGEEXUDATEDISC EDEMA GRADE 0--- GRADE 1--- GRADE GRADE 3++- GRADE 4 +++

GRADE 1 HTR GENERALIZED ARTERIOLAR ATTENUATION BROADENING OF ARTERIOLAR LIGHT REFLEX CONCEALMENT OF VEIN AT A-V CROSSINGS

GRADE 2 HTR SEVERE GENERALIZED AND FOCAL ARTERIOLAR CONSTRICTION A-V CROSSING CHANGES (SALUS SIGN)

GRADE 3 HTR Copper wiring of arterioles Venous banking distal to A-V crossing (bonnet’s sn) Venous tapering on either side of crossing (gunn’s sn) Right angle deflection of veins. Flame shaped hemorrhages cotton wool spots, hard exudates.

GRADE 4 HTR All changes of grade 3 Silver wiring of arterioles Disc edema

Ocular associations of hypertension 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... Classic Appearance Classic Appearance Mildest Form

CRVO NON ISCHAEMICISCHAEMIC

62/F PR No CRVO IVTA(elsewhere)

Baseline 20/500 3 weeks 20/500 3 months 20/200 62/F PR No CRVO (S/P IVTA) 2nd IVTA 2nd IVTA 5 months 20/400 8 months 20/100 Avasti n 2nd Avastin 2nd Avastin

Hayreh et al – Non – Ischaemic : Due to simple occlusion of retinal venous system Non – Ischaemic : Due to simple occlusion of retinal venous system Ischaemic : Due to combined occlusion of the arterial & venous circulation Ischaemic : Due to combined occlusion of the arterial & venous circulation Green et al – Thrombus formation in the region of lamina cribrosa is the primary event CRVO

Complications / Sequelae...  Macular oedema  Haemorrhage  Ischaemia stimulates neovascularization in Optic disc Optic disc Retina Retina Angle Angle Iris - Rubeosis may cause Neovascular Glaucoma Iris - Rubeosis may cause Neovascular Glaucoma  Rhegmatogenous RD  Vascular complications Microaneurysyms Microaneurysyms Optociliary vessels – collaterals between retinal & ciliary vessels Optociliary vessels – collaterals between retinal & ciliary vessels CRVO

Cilioretinal artery occlusion Combined with CRVO

Cilioretinal artery occlusion Combined with anterior ischaemic optic neuropathy

HRVO...

Superior & Inferior vein do not merge into Central Vein before entering into lamina cribrosa Superior & Inferior vein do not merge into Central Vein before entering into lamina cribrosa Like CRVO, only superior or inferior half involved Like CRVO, only superior or inferior half involved Types Types - 2/3 rd :Venous stasis - 1/3 rd :Haemorrhagic Rest Rx or management same as CRVO Rest Rx or management same as CRVO

BRVO...

45/M PR No BRVO

Baseline 20/500 STT 3 weeks 20/500 Avastin 6 weeks/8 m 20/80 45/M PR No BRVO

BRVO

BRVO... Portion of retina involved Portion of retina involved Mostly temporal Mostly temporal - 62% Superotemporal - 38% Inferotemporal Nasal – uncommon & asymptomatic Nasal – uncommon & asymptomatic Occurs exclusively at arterial overcrossing at AV intersection by a thrombus Occurs exclusively at arterial overcrossing at AV intersection by a thrombus

Investigations in RVO... Hb/CBC/ESR/Platelet count Hb/CBC/ESR/Platelet count BSL – Fasting/PP BSL – Fasting/PP BP BP Sr. Lipid Profile Sr. Lipid Profile IOP Measurement IOP Measurement FFA FFA ANA/Anti-ds DNA ANA/Anti-ds DNA VDRL/FTA-Abs VDRL/FTA-Abs LE Cell LE Cell

In Young... Protein C levels Protein S levels Platelet Analysis Sr. & Urine for Homocysteine levels

Others... Hb Electrophoresis PT / PTT Anti-Phospholipid antibody Complete Cardiovascular evaluation

Traditional Rx Options... To treat the associated systemic diseases To treat the associated systemic diseases (Medical Rx) To treat the ocular complications To treat the ocular complications (Laser or Sx) - CRVO Study Group - BRVO Study Group

Retinal artery macroaneurysm Retinal artery macroaneurysm Ocular associations of hypertension

Anterior ischaemic optic neuropathy Anterior ischaemic optic neuropathy Ocular associations of hypertension

Ocular motor nerve palsies Ocular associations of hypertension