HYPERTENSIVE RETINOPATHY

ANGEL DAS

Hypertensive Retinopathy

• Fundus changes that occur in patients with severe hypertension

• Clinical presentation includes changes of -Retinopathy -Choroidopathy -Optic neuropathy

pathogenesis

• 3 factors play role in pathogenesis1. Vasoconstriction2. Arteriosclerotic changes3. Increased vascular permeability

Pathophysiology

Systemic chronic

hypertensionArteriosclero

sis Narrowing of retinal arterioles

Retinal Ischaemia Hypoxia

Increased capillary

permeability

Focal Retinal Oedema, retinal haemorrhage,cotton wool

spots, hard exudates

Clinical types

Clinically hypertensive fundus changes can be described as• Chronic hypertensive retinopathy• Malignant/acute hypertensive retinopathy

Chronic hypertensive retinopathy

• Usually asypmtomatic• Clinical situations include

1.Hypertension with involutinary ( senile) sclerosis:elderly patients (> 50 yrs ),fundus changes comprise augmented

arteriosclerotic retinopathy.

2.Chronic hypertension with compensatory arteriolar sclerosis

• Seen in young individuals • young arterioles respond to HTN by prolifrative

and fibrous changes in media• In the kidneys there will be chronic

glomerulonephritis• so known as albuminuric or renal retinopathy

Normal Fundus

Fundus Changes

• Generalized arteriolar narrowing• Focal arteriolar narrowing• A-V nicking -hallmark of HR

• Salu’s sign – deflection of veins at A-V crossing• Bonnet sign – banking of veins distal to A-V crossing• Gunn sign – tapering of veins on either side of crossing

• Arteriolar Reflex Changes -bright, thin, linear reflex –Normal -diffuse, less bright reflex –Grade I/II -Copper wiring -Silver wiring

• Superficial retinal haemorrhages• Hard exudates• Cotton wool spots

Malignant hypertension

• rapid progression of the hypertensive state in a patient with relatively young arterioles undefended by sclerosis

• There will be retinopathy , choroidopathy & optic neuropathy

• It is asso. With renal insufficiency

Choroidopathy

• Elschnig’s spots- focal areas infarcted retinal pigment epithelium

• Siegrist streaks- due to fibrinoid necrosis in malignant hypertension

Grade I

Mild generalised arteriolar attenuation

Broadening of arteriolar light reflex

Vein concealment

Grading ( Keith & Wegner)

Grade II

Marked generalised narrowing and focal attenuation of artertioles

Salus’ Sign (deflection of veins at AV crossings)

Grade III

Copper wiring of arterioles

Bonnet Sign (banking of veins distal to av crossings)

Gunn Sign (tapering of vein on either side of av crossings)

Flame shaped haemorrhages,

Cotton wool spots Hard exudates

Gunn SignBonnet sign

Grade IV

Grade III changes

Silver wiring of arterioles

Papilloedema

• Scheie classification

ManagementMild HR BP control only

Moderate HR BP control +Assess cholesterol levels & if indicated cholesterol lowering agents

Accelerated HR Urgent anti hypertensive management by stepwise control of BP over a few hours

BP >160/100mm Hg- > 200/130mm Hg

Narrowing of nasal arterioles-generalised

Cotton wool spots; retinal hemmorhages- retinal hypoxia

‘Macular star’ – ‘flat macular detachment’

Retinopathy in PIH

Management

• Changes are reversible , disappear after delivery• In preorganic stage : conservative treatment , pregnancy

is continued under close observation• Advent of hypoxic retinopathy( cotton wool

spots,hemorrhages,retinal edema): indication for termination of pregnancy ,otherwise permanent visual loss or even loss of life may occur.