Hypertensive retinopathy AP.박영훈/R2 임성아

Hypertension BP ↑  Arterial constriction ( by auto-regulation) Arteriosclerosis Leakage Eye exam may yield the first clue to relative asymptomatic systemic disease

Hypertensive retinopathy Chronically SBP  Retinal vascular changes Acutely elevated SBP Retina Choroid Optic nerve changes

Chronic hypertensive retinopathy BP ↑ →focal arteriolar constriction Narrowing and irregularity of retinal arteries Arteriolar light reflex ↑ Loss for transparency of the intra-arterial blood column Arteriovenous nicking Narrowing of retinal veins at arteriovenous crossing sites Hallmark The course of the vein may change to a more perpendicular direction as well. If there is impedance to flow, the segment of the vein distal to the constriction appears larger, darker, and more tortuous.

DDx Diabetic retinopathy Retinal venous obstruction Hyperviscosity syndromes Congenital hereditary retinal arterial tortuosity Ocular ischemic syndrome Radiation retinopathy 1. arteriovenous crossing changes, presence of collateral vessels, and dilated capillary bed. 2. telangiectatic vessels on the optic nerve head and intraretinal hemorrhages temporal to the macula. 3. retinal arterioles and the early arteriovenous crossing changes.

Chronic hypertensive retinopathy Prolonged duration of HBP ->Breakdown of inner blood-retinal barrier ->Extravasation of plasma and RBC Retinal hemorrhage Microaneurysms Cottonwool spots Intraretinal lipid 2nd complication Retinal vascular occlusive disease, Macroaneurysm formation NAION

Arteriosclerosis and hypertension Normal Arteriole : A:V ratio = 2:3 (normal) Thin line of reflected light in the middle of the blood column Sclerotic change Increasing thickening of the arteriolar wall Abnormal : broader, duller, more diffuse reflex “Silver wire” : blood column no longer be visualized Nicking (Gunn’s sign) : compression of the venule Salus’ sign : more obtuse angle at A-V crossing site as involutional sclerosis, also occur in the normal aging population The appearance of the ocular fundus in hypertension is related directly to the status of the retinal arteries and the rate of rise and degree of systemic blood pressure. The age of the patient may complicate interpretation of the clinical fundus changes. Although arteriolar sclerosis is a finding of long-standing hypertension, these changes, categorized as involutional sclerosis, also occur in the normal aging population.[9] With atherosclerosis alone, mild thickening of the arteriolar wall occurs. Clinically, focal narrowing and straightening of the retinal arterioles are seen in the absence of arteriovenous crossing changes.[10] Because the chronic effects of elevated systemic blood pressure occur along with arteriosclerotic thickening of the blood vessel walls, it can be difficult to categorize fundus changes solely on the basis of elevated blood pressure.

Malignant hypertension End-organ damage secondary to systemic arterial hypertension --Directly sensitive to blood pressure (kidneys, eyes, brain, cardiovascular system),

Malignant hypertensive retinopathy Visual sx. Decompensation of the inner blood-retinal barrier Retinal arteriolar spasm. Superficial retinal hemorrhages.  Cotton-wool spots.  Serous retinal detachment.  Optic disc edema. Sx. :headache, scotoma, diplopia, dimness in vision, and photopsia

A prominent cotton-wool spot in the papillomacular bundle is seen, with an adjacent intraretinal hemorrhage Fluorescein angiography shows capillary nonperfusion in the area corresponding to the cotton-wool patch; note the hypofluorescence of the intraretinal hemorrhage, caused by blockage. SRF, flame-shaped hemorrhages 4. Lipid exudation in a macular star configuration DDx Bilateral bullous central serous chorioretinopathy Bilateral central retinal vein obstruction Collagen vascular diseases Diabetic retinopathy (especially in the setting of diabetic papillopathy)

Malignant hypertensive retinopathy Choroidopathy & Retinopathy Elschnig’s spots Siegrist’s streaks Bullous RD       Elschnig’s spots: Focal occlusion of the choriocapillaris leads to necrosis and atrophy of the RPE small. black spots surrounded by yellow halos which represent focal choroidal infarcts. Siegrist’s streaks : Linear configurations of pigmentation along choroidal arteries

Hypertensive choroidopathy Elschnig’s spots Fibrinoid necrosis of choroid a. → Patchy non-perfusion of area of choriocapillaris → patches of RPE appear yellow and leak fluorescein Siegrist’s streaks Linear, hyperpigmentation over choroidal a. Localized bullous RD Breakdown of the inner blood-retinal barrier

Malignant hypertensive retinopathy Optic neuropathy Disc edema AION      

G ra d e I " no n - ma li gna t II l ig a t" or “ac c r ate d” R e t i na l c h a n ge s Prog n o sis Revised grading system for Hypertensive Retinopathy [Dodson, Lip, Eames et al JHH 1996] G e n r al is d ar t er i o l arro w g or to u s y Focal co ns c on May d e p nd on h i gh t of B P, b u t ag a n d o r ca ova s c ul ar sk fa tor s e q l ly m orta t. H aemo r h age s , ar d ex ud ate co t to n woo l s pot ± op ti c i sc w e l li ng Mo st ca s e s di e w i t hi n 2 yea rs f u r eat d. In tr ate d p at , m d a viva l is ow > 12 yea In order for cotton wool spots to develop from hypertension, autoregulatory mechanisms must first be overcome. For this to happen, the patient must have at least 110mmHg diastolic readings. Patients who develop papilledema from hypertension have malignant hypertension and typically have BP in the range of 250/150mmHg Fluorescein angiography is not indicated in cases of hypertensive retinopathy as it yields no diagnostic information. Hypertensive retinopathy presents with a ‘dry’ retina (few hemorrhages, rare edema, rare exudate, and multiple cotton wool spots) whereas diabetic retinopathy, in comparison, presents with a ‘wet’ retina (multiple hemorrhage, multiple exudate, extensive edema, and few cotton wool spots).

Keith-Wagener-Barker Classification Group I Minimal constriction of retinal arterioles, Some tortuosity Group II More definite focal narrowing and AV nicking Minimal or no other systemic involvement Group III Hemorrhages, exudates, cotton-wool spots Group IV Group III + optic disc edema Elschnig’s spots Severe cardiac, cerebral, or renal dysfunction Reitnopaty & prognosis 1, 2 –arteriosclerosis change 반영 3,4 –vascular penetration, ischemic change 반영

Scheie classification (1) Arteriosclerosis Stage 0 No visible vascular abnormalities Stage I Diffuse narrowing of arteriole, no focal constriction Stage II Pronounced narrowing, with focal constriction Stage III Stage II + retinal hemorrhages Stage IV Stage III + retinal edema, HE, optic disc edema In order for cotton wool spots to develop from hypertension, autoregulatory mechanisms must first be overcome. For this to happen, the patient must have at least 110mmHg diastolic readings. Patients who develop papilledema from hypertension have malignant hypertension and typically have BP in the range of 250/150mmHg Fluorescein angiography is not indicated in cases of hypertensive retinopathy as it yields no diagnostic information. Hypertensive retinopathy presents with a ‘dry’ retina (few hemorrhages, rare edema, rare exudate, and multiple cotton wool spots) whereas diabetic retinopathy, in comparison, presents with a ‘wet’ retina (multiple hemorrhage, multiple exudate, extensive edema, and few cotton wool spots).

Scheie classification (2) Arteriole wall Stage 0 Normal Stage 1 Broadening of the light reflex from the arteriole No AV compression Stage 2 Light reflex & crossing changes are more prominent Stage 3 “Copper wire” appearance of arteriole More AV compression Stage 4 “Silver wire” appearance of arteriole Most severe AV compression

Managementma Appropriate treatment of the underlyig hypertension If a patient presents with papilledema from hypertension, then the patient has should be considered to be in medical crisis

Clinical Pearls CWS from hypertension, dBP >110mmHg Papilledema from hypertension , range of 250/150mmHg Fluorescein angiography is not indicated in cases of hypertensive retinopathy Hypertensive retinopathy presents with a ‘dry’ retina (few hemorrhages, rare edema, rare exudate, and multiple cotton wool spots) whereas diabetic retinopathy, in comparison, presents with a ‘wet’ retina (multiple hemorrhage, multiple exudate, extensive edema, and few cotton wool spots).

Reference Stephen J. Ryan : RETINA, 4th Edition ; Chapter 74. Hypertension Yanoff & Duker: Ophthalmology, 3rd Edition ; Chapter 6.15 - Hypertensive Retinopathy Images. Google.com

Thank you for listening Reference 6th Kanski clinical ophthalmology