HYPERTENSIVE RETINOPATHY Dr. Shinisha Paul

introduction Ophthalmic findings of end organ damage secondary to systemic hypertension affects precapillary arterioles and capillaries Uncontrolled systemic hypertension leads to nonperfusion at various retinal levels and to neuronal loss

Retinal blood supply Retinal blood vessels and choroidal blood vessels Ophthalmic artery central retinal artery posterior ciliary arteries long posterior ciliary Short posterior ciliary Anterior choriocapillaries Posterior choriocapillaries

Outer layers are avascular – diffusion from the choriocapillaries Central retinal artery – end artery Retinal veins are in inner retina and interdigitate with veins Artery lies anterior to vein (common adventitial coat)

Pathophysiology Arteriosclerosis – breakdown in autoregulation High pressure in arterioles transmitted to capillaries Capillary closure or hemorrhage

Clinical features Asymptomatic Headache Blurred vision Transient vision loss

Changes in hypertensive retinopathy Focal arteriolar narrowing and arterial venous nicking – sclerosis Flame hemorrhages blot hemorrhages Microaneurysm hard exudates Cotton wool spots Optic disc swelling

AV crossing changes: Venous deflection – salus sign Venous nipping – gunn sign Distal banking – bonnet sign

Classification Keith Wagner and Barker Grade 1 - Mild to moderate narrowing Grade 2 - a. There is moderate to marked narrowing of retinal arterioles. b. Copper wire reflex c. Typical arteriovenous crossing changes Grade 3 – a. retinal arteriolar narrowing and focal constriction. b. Silver wire appearance c. Retinal oedema d. Cotton wool or soft exudates e. Superficial flame-shaped haemorrhages

Grade 4 : grade 3 and macular star with papilledema

Modified Scheie Classification of "Hypertensive Retinopathy": Grade 0 - No changes Grade 1 - Barely detectable arterial narrowing Grade 2 - Obvious arterial narrowing with focal irregularities Grade 3 - Grade 2 plus retinal hemorrhages and/orexudates Grade 4 - Grade 3 plus disc swelling

Hypertensive Choroidopathy 2018/2/5 Typically occurs in young patients episode of acute hypertension associated with preeclampsia, eclampsia, pheochromocytoma, or renal hypertension Elschnig spots - non perfused choriocapillaries Siegrist streaks - hyperpigmented streaks

2018/2/5

2018/2/5

Pregnancy induced hypertension 2018/2/5 Hypertension in pregnant women after 20 weeks of gestation Symptoms : Rapid or sudden weight gain, high blood pressure, protein in the urine, and swelling in the hands, feet, and face Blurry vision, spots before your eyes that don’t resolve. Related to vascular endothelial dysfunction Exudative retinal detachment - choroidal ischemia

Risk factors for PIH Is under age 20 or over age 35 2018/2/5 Is under age 20 or over age 35 Has a history of chronic hypertension Has a previous history of PIH Has a female relative with a history of PIH Is underweight or overweight Has diabetes before becoming pregnant Has an immune system disorder, such as lupus or rheumatoid arthritis Has kidney disease Has a history of alcohol, drug, or tobacco use Is expecting twins or triplets

Treatment Grade 1-3 : control of hypertension Grade 4 : immediate intervention (Malignant hypertension) PIH : regular fundus examination

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