Hypertensive Retinopathy Dr.Vijay

Definition What is Hypertensive Retinopathy? Hypertensive retinopathy is retinal vascular damage caused by hypertension.

Pathophysiology Arteriosclerosis and atherosclerosis predominates Systermic chronic hypertension Arteriosclerosis and atherosclerosis predominates Narrowing of retinal arterioles Retinal Ischaemia Hypoxia Increased capillary permeability Focal Retinal Oedema, retinal haemorrhage,cotton wool spots, hard exudates

Clinical Manifestation Most patients are asymptomatic. Some present with headaches and blurred vision. On ophthalmoscopy : Generalized arteriolar narrowing Changes of the arterovenous crossings  Flame haemorrhage  Microaneurysms  Exudates  Arteriolar macroaneurysms  Cotton-wool spots Optic disc swelling  FIPT ( Focal Intraretinal Periarteriolar Transudates)

1. The cardinal funduscopic feature of malignant hypertension is disk swelling, which appears as blurring and elevation of disk margins. The top image also shows a characteristic star-shaped macular lesion caused by leaking retinal vessels; the bottom image also shows a characteristic flame-shaped hemorrhage and dilated veins. 2. Moderate hypertensive retinopathy is characterized by thinned, straight arteries; intraretinal hemorrhages; and yellow hard exudates (top). Cotton-wool spots (bottom) are an additional feature of moderate hypertensive retinopathy. They are caused by focal axonal swelling of the retinal nerve fiber layer as a result of small-vessel occlusion.

Retinal arteriolar narrowing due to thickening and opacification of arteriolar walls (copper wiring) caused by hypertensive arteriosclerosis. Image also shows macular edema.

Classification Keith-Wagener-Barker classification Grade Description Slight narrowing, sclerosis, and tortuosity of the retinal arterioles; mild, asymptomatic hypertension Grade 2 Definite narrowing, focal constriction, sclerosis, and AV nicking; blood pressure is higher and sustained; few, if any, symptoms referable to blood pressure Grade 3 Retinopathy (cotton-wool patches, arteriolosclerosis, hemorrhages); blood pressure is higher and more sustained; headaches, vertigo, and nervousness; mild impairment of cardiac, cerebral, and renal function Grade 4 Neuroretinal edema, including papilledema; Siegrist streaks, Elschnig spots; blood pressure persistently elevated; headaches, asthenia, loss of weight, dyspnea, and visual disturbances; impairment of cardiac, cerebral, and renal function

Diagnosis Diagnosis is made by thorough history of the patient, ophthalmoscopy (direct or indirect) and also physical examination. History May reveal decrease of patient vision, occipital headache and high blood pressure.  Physical examination May detect elevation of blood pressure Ophthalmoscopy Show changes in arteriovenous crossings Cotton-wool spot Flame haemorrhage Silver wire appearance of narrowed arterioles Nicking of veins where arteries cross them (arteriovenous nicking) Hard exudates “lipids deposites” “Macular star” Flame shape haemorrhage Retinal oedema Swelling of the optic nerve Aterial microaneurysms Arteriolar macroaneurysms  

Differential Diagnosis Diabetic retinopathy Collagen vascular diseases

Management A major aim of treatment is to prevent, limit, or reverse such target organ damage by lowering the patient's high blood pressure. Lifestyle changes  Promote Healthy lifestyle; exercise, healthy foods Advice patient to reduce the Blood Pressure Taking the medication accordingly Referral to medical team

Complications of hypertensive retinopathy include: Blindness Reduce in vision