1. Update on Hypertensive Retinopathy
Dkt. Muchai Gachago

2. Introduction First described in the late 1800s
Used to predict risk of stroke, cardiovascular disease, and even mortality
Epidemiology
HR in 3% to 14% of nondiabetic adults age ≥40.
10 year cumulative incidence is 16%.

3. PATHOGENESIS AND PRESENTATION
spectrum of “retinal vascular signs” caused by elevated blood pressure.
Autoregulation of the vasculature → breakdown of autoregulation pathways and atherosclerosis

4. Signs

5. Signs

6. Signs

7. Signs

8. Signs

9. Long-term Consequences
Arteriolosclerosis - irreversible→opacification, compression of venules.
BRB disruption→“exudative” stage
“Malignant” stage → optic disc and macular oedema due to raised intracranial pressure.

10. Keith–Wagener–Barker Classification
Grade
Features 1
Mild generalized retinal arteriolar narrowing 2
Definite focal narrowing and arteriovenous nipping 3
Signs of grade 2 retinopathy plus retinal hemorrhages, exudates, and cotton wool spots 4
Severe grade 3 retinopathy plus papilloedema
-Poor reliability and reproducibility
-Grades do not correlate with severity of hypertension
-Not sequential in nature
-Grades do not correlate with prognosis, cardiovascular events, and mortality.

11. Simplified Classification
Grade
Features
Mild
( retinal arteriolar signs)
Generalized arteriolar narrowing, focal arteriolar narrowing, arteriovenous nicking, opacity (“copper wiring”) of arteriolar wall, or a combination of these signs
Moderate
(retinopath y-like lesions)
Retinal hemorrhages (blot-shaped, dot-shaped, or fiame-shaped), microaneurysms, cotton wool spots, hard exudates, or a combination of these signs
Malignant
Signs of moderate retinopathy plus optic disk swelling
-Good reliability and reproducibility.
-Predicted the long-term risk of stroke.
-Ease of use
-Appropriate stratification of cardiovascular risk disease.

12. Recent Observations
↑blood pressure →higher frequency of retinopathy signs
Long-term hypertension → Generalized retinal arteriolar narrowing & AVN. Assoc with ↑BP control in past 10yrs
Focal arteriolar narrowing and retinopathy lesions related only to concurrently measured blood pressure.
Assoc between BP and retinal microvascular signs ↓with age
Smaller retinal arteriolar and larger venular calibers precede clinical stages of hypertension and predict the risk of hypertension in initially normotensive individuals.

13. RELATIONSHIP WITH TARGET ORGAN DAMAGE
Atherosclerosis Risk in Communities (ARIC) study, subjects with HR:
↑ risk of developing incident stroke
Cognitive decline
Cerebral white matter lesions
Cerebral atrophy
Predicted the long-term risk of stroke
Incident stroke (19.3% vs 4.3%) and incident cerebral infarction (15.5% vs 3.6%)

14. Kidney and Heart Disease
↑Chronic kidney disease (CKD) & microalbuminuria
Stroke * 7
Heart attack * 4
Coronary artery disease * 3
Peripheral artery disease * 2

15. Systemic Associations
CLINICAL MANAGEMENT
Retinopathy Grade
Systemic Associations
Management
Mild
Weak associations with stroke, coronary heart disease and cardiovascular mortality
Routine care
Closer monitoring of vascular risk
Moderate
Strong association with stroke, congestive heart failure, renal dysfunction, and cardiovascular mortality
Exclude diabetes
Possible indication for hypertension treatment and other risk factors
Malignant
Associated with mortality
Urgent hypertension treatment

16. Hypertensive Choroidopathy
Elschnig Spots: Focal choroidal infarcts
Siegrist Streaks: Fibrinoid necrosis
Exudative RD

17. Complications

18. Complications

19. Complications

21. Further Reading
Retinal Physician, Volume: 10 , Issue: November 2013, page(s): 43 – 54...Review Article Reviewing 96 papers on Hypertension and HR.