1. Hypertensive retinopathy
AP.박영훈/R2 임성아

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

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

4. 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.

5. 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.

6. 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

8. 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.

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

11. 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

12. 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)

13. 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

14. 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

16. Malignant hypertensive retinopathy
Optic neuropathy
Disc edema
AION      

17. G ra d e I
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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
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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).

18. 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

19. 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).

20. 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

23. 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

24. 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).

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

26. Thank you for listening
Reference
6th Kanski clinical ophthalmology