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Hypertensive Retinopathy

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Hypertensive Retinopathy

  1. 1. Hypertensive Retinopathy
  2. 2. Hypertensive Retinopathy <ul><li>Prevalence </li></ul><ul><li>Symptoms </li></ul><ul><li>Diagnostic techniques and signs </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Associated conditions </li></ul><ul><li>Management </li></ul>
  3. 3. Hypertensive Retinopathy - Introduction <ul><li>Bilateral </li></ul><ul><li>Symmetrical </li></ul><ul><li>Small blood vessel disease </li></ul><ul><li>Caused by systemic hypertension </li></ul><ul><ul><li>Acute or chronic </li></ul></ul><ul><ul><li>Systolic or diastolic </li></ul></ul><ul><li>End organ disease manifestation </li></ul>
  4. 4. Hypertensive Retinopathy - Prevalence <ul><li>The second most common retinal vascular disease </li></ul><ul><li>Systemic hypertension (>160/90mmHg) 10-15% in the UK >40 age group </li></ul><ul><li>Malignant hypertension (240/140mmhg) 0.5-0.75% </li></ul><ul><li>Hypertensive retinopathy 4-10% </li></ul>
  5. 5. Hypertensive Retinopathy – Prevalence, Risk factors <ul><li>Afro-Caribbeans = relative risk factor 2x </li></ul><ul><li>Age </li></ul><ul><li>Family history </li></ul><ul><li>Medications </li></ul><ul><li>Obesity </li></ul><ul><li>Smoking </li></ul><ul><li>Stress </li></ul><ul><li>Alcohol consumption </li></ul><ul><li>Lack of exercise </li></ul>
  6. 6. Hypertensive Retinopathy – Prevalence, Morbidity Risk <ul><li>Stroke (7x) </li></ul><ul><li>Heart attack (4x) </li></ul><ul><li>Coronary artery disease (3x) </li></ul><ul><li>Peripheral artery disease (2x) </li></ul>
  7. 7. Hypertensive Retinopathy – History & Symptoms <ul><li>Possible history of systemic hypertension </li></ul><ul><li>Systemic hypertension largely asymptomatic </li></ul><ul><li>Hypertensive retinopathy largely asymptomatic </li></ul><ul><li>The eye examination will often give the first clue of systemic hypertension </li></ul>
  8. 8. Hypertensive Retinopathy – Diagnostic Techniques & Signs <ul><li>Ophthalmoscopy (non-malignant retinopathy) </li></ul><ul><ul><li>Arteriosclerosis from chronic disease </li></ul></ul><ul><ul><ul><li>focal arteriolar narrowing </li></ul></ul></ul><ul><ul><ul><li>arterio-venous crossing changes </li></ul></ul></ul><ul><ul><ul><ul><li>venous constriction and deflection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>distal banking </li></ul></ul></ul></ul><ul><ul><ul><li>arteriolar colour changes </li></ul></ul></ul><ul><ul><ul><li>vessel sclerosis </li></ul></ul></ul><ul><ul><li>Similar signs with ageing </li></ul></ul><ul><li>Sphygmomanometry </li></ul><ul><ul><li>blood pressure measurement is required to make a positive diagnosis in the absence of malignant retinopathy changes </li></ul></ul>
  9. 9. Hypertensive Retinopathy – Diagnostic Techniques & Signs <ul><li>Arteriolar Narrowing </li></ul><ul><ul><li>Young patients, autoregulation causes uniform narrowing of retinal arterioles </li></ul></ul><ul><ul><li>Older patients, arteriosclerosis and autoregulation cause focal arteriolar narrowing </li></ul></ul><ul><ul><li>Assess the arterio-venous calibre ratio as a percentage </li></ul></ul><ul><ul><ul><li>adjacent arteries and veins </li></ul></ul></ul><ul><ul><ul><li>equivalent numbers of bifurcations </li></ul></ul></ul><ul><ul><ul><li>between 1 and 3 DD from optic disc </li></ul></ul></ul>
  10. 10. Hypertensive Retinopathy – Diagnostic Techniques & Signs Generalised narrowing of the retinal arterioles
  11. 11. Hypertensive Retinopathy – Diagnostic Techniques & Signs Focal narrowing of the retinal arterioles – Copper and Silver Wiring
  12. 12. Hypertensive Retinopathy – Diagnostic Techniques & Signs <ul><li>Tortuosity of the retinal arterioles </li></ul><ul><ul><li>not, in itself, a sign of hypertensive retinopathy </li></ul></ul><ul><ul><li>segmental arteriolar tortuosity is such a sign </li></ul></ul><ul><ul><ul><li>commonly found in the nasal retina </li></ul></ul></ul><ul><ul><li>Almost 80% of patients with hypertension do not show tortuosity </li></ul></ul><ul><ul><li>A standard 5 point grading scale can be used </li></ul></ul><ul><ul><li>Record tortuosity type, severity and location </li></ul></ul>
  13. 13. Hypertensive Retinopathy – Diagnostic Techniques & Signs <ul><li>Arteriosclerosis </li></ul><ul><ul><li>Thickening of the arteriolar wall </li></ul></ul><ul><ul><li>Assess using the arteriolar reflex </li></ul></ul><ul><ul><ul><li>brightness </li></ul></ul></ul><ul><ul><ul><li>thickness ratio </li></ul></ul></ul><ul><ul><li>Assess using arterio-venous crossing changes </li></ul></ul><ul><ul><ul><li>venous deflection (Salus’ sign) </li></ul></ul></ul><ul><ul><ul><li>localised venous narrowing (nipping; Gunn’s sign) </li></ul></ul></ul><ul><ul><ul><li>right-angled crossing caused by venous deflection </li></ul></ul></ul><ul><ul><ul><li>venous distal banking (Bonnet’s sign) </li></ul></ul></ul>
  14. 14. Hypertensive Retinopathy – Diagnostic Techniques & Signs Gunn’s sign & right-angled crossing Bonnet’s sign
  15. 15. Hypertensive Retinopathy – Diagnostic Techniques & Signs Gunn’s sign, right-angled crossing & Bonnet’s sign Salus’ sign?
  16. 16. Hypertensive Retinopathy – Diagnostic Techniques & Signs <ul><li>Malignant Hypertensive Retinopathy </li></ul><ul><ul><li>A:V ratio of 25% & arterial reflex ratio of 60% </li></ul></ul><ul><ul><ul><li>“ copper wiring” </li></ul></ul></ul><ul><ul><li>A:V ratio of <20% & arterial reflex ratio of 100% </li></ul></ul><ul><ul><ul><li>“ silver wiring” </li></ul></ul></ul><ul><ul><li>cotton wool spots </li></ul></ul><ul><ul><li>hard exudates </li></ul></ul><ul><ul><li>dot and flame shaped haemorrhages </li></ul></ul><ul><ul><li>if advanced – retinal or macula oedema or papilloedema </li></ul></ul><ul><ul><li>all non-advanced changes due to focal hypoperfusion </li></ul></ul><ul><ul><li>note presence, number, size, position (photograph!) </li></ul></ul>
  17. 17. Hypertensive Retinopathy – Diagnostic Techniques & Signs Early malignant Dot and blot haemorrhages Hard and soft exudates Diffuse arteriolar narrowing Arterio-venous crossing defects
  18. 18. Hypertensive Retinopathy – Diagnostic Techniques & Signs Advanced malignant Macular star Pailloedema
  19. 19. Hypertensive Retinopathy - Classification <20% Malignant abnormalities encountered in Grades I through III, as well as swelling of the optic nerve head and macular star IV 25% Malignant abnormalities seen in Grades I and II, as well as retinal haemorrhages, hard exudation, and cotton-wool spots III 33% Non-malignant narrowing of the retinal arteries in conjunction with regions of focal narrowing and arterio-venous nipping II 50% Non-malignant minimal narrowing of the retinal arteries I A:V ratio Alternative description Description Grade
  20. 20. Hypertensive Retinopathy – Classification Grade 2
  21. 21. Hypertensive Retinopathy – Classification Grade 3
  22. 22. Hypertensive Retinopathy – Classification Grade 4
  23. 23. Hypertensive Retinopathy – Classification <ul><li>HR grades I and II are typically chronic </li></ul><ul><li>HR grades III and IV are typically acute </li></ul><ul><ul><li>diastolic blood pressure >= 110 correlates with grade III </li></ul></ul><ul><ul><li>diastolic blood pressure >= 130 correlates with grade IV </li></ul></ul>
  24. 24. Hypertensive Retinopathy – Choroidopathy <ul><li>Hypertensive choroidopathy frequently occurs with grade IV Hypertensive Retinopathy </li></ul><ul><ul><li>yellow spots (Elshnig Nodules) are visible at the level of the retinal pigment epithelium </li></ul></ul><ul><ul><li>hyperfluorescent on fluorescein angiography </li></ul></ul><ul><ul><li>secondary to arteriosclerosis within the choriocapillaris </li></ul></ul><ul><ul><li>in severe cases they cause serous retinal detachment </li></ul></ul><ul><ul><li>resolve to become pigmented or depigmented </li></ul></ul><ul><ul><li>linear groups of spots occur they are referred to as Siegrist's streaks </li></ul></ul>
  25. 25. Hypertensive Retinopathy – Pathophysiology <ul><li>A disease of the retinal microvasculature </li></ul><ul><li>Cholesterol deposition in the tunica intima of medium and large arteries </li></ul><ul><ul><li>reduction in the lumen size of these vessels </li></ul></ul><ul><li>Arteriolosclerosis causes a breakdown in autoregulation </li></ul><ul><ul><li>the high pressures in the arterioles are transmitted to the retinal capillaries </li></ul></ul><ul><ul><li>capillary closure or haemorrhage occurs </li></ul></ul>
  26. 26. Hypertensive Retinopathy – Pathophysiology <ul><li>Dot haemorrhages are ruptures of the deep capillary bed </li></ul><ul><ul><li>leakage of blood into the outer plexiform layer </li></ul></ul><ul><ul><li>their depth leads to a round, small area of blood </li></ul></ul><ul><ul><li>Phagocytosis of the red and white blood cells leaves hard exudates </li></ul></ul><ul><ul><li>the hard exudates are at a similar depth and have a similar size (slightly larger) and shape to the dot haemorrhages </li></ul></ul><ul><ul><li>hard exudates will last for more than 12 months, even following successful treatment. </li></ul></ul>
  27. 27. Hypertensive Retinopathy – Pathophysiology <ul><li>Flame shaped haemorrhages are ruptures of the superficial capillary bed </li></ul><ul><ul><li>the blood disperses within the retinal nerve fibre layer </li></ul></ul><ul><li>Either capillary rupture or capillary closure gives: </li></ul><ul><ul><li>RGC oxygen starvation </li></ul></ul><ul><ul><li>RGC waste removal failure </li></ul></ul><ul><ul><li>Axoplasmic transport failure </li></ul></ul><ul><ul><ul><li>accumulation of waste material at the boundary between perfused and non-perfused retina </li></ul></ul></ul><ul><ul><ul><li>clinically visible as cotton wool spots (CWS) </li></ul></ul></ul><ul><li>In extreme cases, disc oedema </li></ul><ul><ul><li>a hypertension-related increase in intracranial pressure </li></ul></ul>
  28. 28. Hypertensive Retinopathy – Pathophysiology <ul><li>Arteriosclerotic changes persist after Tx </li></ul><ul><li>Hypertensive retinopathy changes resolve over time following Tx </li></ul><ul><ul><li>Cotton wool spots develop in 24 to 48 hours with the elevation of blood pressure, and resolve in 2 to 10 weeks </li></ul></ul><ul><ul><li>A macular star develops within several weeks of the development of elevated blood pressure and resolves within months to years </li></ul></ul><ul><ul><li>Papilloedema develops within days to weeks of increased blood pressure and resolves within weeks to months </li></ul></ul><ul><ul><li>Visual recovery is limited if the macula or optic nerve have been affected </li></ul></ul>
  29. 29. Hypertensive Retinopathy – Management <ul><li>Appropriate treatment of the underlying hypertension </li></ul><ul><li>If the patient is previously undiagnosed the patient needs referral to their general practitioner for assessment </li></ul><ul><li>A grade I or grade II hypertensive retinopathy </li></ul><ul><ul><li>non-urgent referral </li></ul></ul><ul><li>A grade III hypertensive retinopathy </li></ul><ul><ul><li>more urgent referral to the GP </li></ul></ul><ul><li>A grade IV hypertensive retinopathy </li></ul><ul><ul><li>Px is in medical crisis. This patient needs immediate referral to a hospital eye casualty department </li></ul></ul>
  30. 30. Hypertensive Retinopathy – Associated Conditions <ul><li>Branch retinal artery occlusion (BRAO) </li></ul><ul><li>Central retinal artery occlusion (CRAO) </li></ul><ul><li>Branch retinal vein occlusion (BRVO) </li></ul><ul><li>Central retinal vein occlusion (CRVO) </li></ul><ul><li>Non-arteritic anterior ischaemic optic neuropathy (NAION) </li></ul>
  31. 31. Hypertensive Retinopathy – Clinical Pearls <ul><li>If CWS are present, autoregulation has failed: diastolic BP >110mmHg </li></ul><ul><li>Papilloedema means malignant hypertension BP > 250/150mmHg </li></ul><ul><li>Fluorescein angiography is not indicated as it provides no diagnostic information </li></ul>
  32. 32. Hypertensive Retinopathy – Clinical Pearls Wet retina: multiple haemorrhages extensive oedema multiple exudates few cotton wool spots rare flame-shaped haemorrhages visibly abnormal retinal veins and capillaries <ul><ul><li>Dry retina: </li></ul></ul><ul><ul><li>few haemorrhages </li></ul></ul><ul><ul><li>rare oedema </li></ul></ul><ul><ul><li>rare exudate </li></ul></ul><ul><ul><li>multiple cotton wool spots </li></ul></ul><ul><ul><li>flame-shaped haemorrhages </li></ul></ul><ul><ul><li>visibly abnormal retinal arteries </li></ul></ul>Diabetic Retinopathy Hypertensive Retinopathy

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