Hypertensive Retinopathy Grades Colour Fundus Photography Retinal angiography

1. Presenter:
Dr. Md. Rezwanul Hasan
Long Term Fellow, Vitreo-Retina

2. •Hypertension is a risk factor for many
systemic conditions that cause serious
morbidity and mortality. It affects over 1.13
billion people worldwide.
•Hypertension can have various effects on
the eyes, including the development of
retinopathy, choroidopathy, and optic
neuropathy. conditions.
•The most common ocular presentation of
hypertension is hypertensive retinopathy.
Introduction

3. Pathophysiology of Hypertensive Retinopathy
Vasoconstrictive
Phase:
Elevated luminal
pressures.
Local autoregulation
narrows retinal
arterioles.
Vasospasm reduces
blood flow.
Sclerotic Phase:
Endothelial wall changes:
•Intimal thickening.
•Medial hyperplasia.
•Hyaline degradation.
Arteriolar changes worsen:
•Arteriolar narrowing.
•Altered AV crossings.
•Silver and copper wiring.
Exudative Phase:
Blood-retinal barrier
disruption.
Leakage of plasma and
blood.
Results in:
•Retinal hemorrhages.
•Hard exudates.
•Retinal ischemia.
•Smooth muscle necrosis.

4. Signs of Hypertensive Retinopathy:
• Constricted and tortuous
arterioles.
• Retinal hemorrhages, hard
exudates, and cotton wool
spots.
• Retinal edema and
papilledema.
• Widening of arteriole reflex,
arteriovenous crossing signs,
and copper/silver wire
arterioles.

11. Classification of Hypertensive Retinopathy
• There are several grading systems
proposed to classify its severity,
including the Keith-Wagener-Barker
classification and the simplified grading
system proposed by Wong and
Mitchell.
• These staging systems serves as a
valuable tool for documenting the
disease's stage and its progression.

12. Classification of
Hypertensive
Retinopathy

14. Diagnosis of Hypertensive Chorioretinopathy
• Retinal imaging, particularly wide-field color fundus
photography, is useful for documenting these findings and
assessing for improvement over time.
• Fluorescein angiography can be helpful in investigating
hypertensive chorioretinopathy, showing patchy and delayed
choroidal filling, severely delayed retinal arterial filling, and
areas of retinal capillary nonperfusion.
• Indocyanine green (ICG) angiography can demonstrate
hypocyanescence of ischemic areas of the choroid.

16. • Optical coherence
tomography of the macula of
the right eye (A) and left eye
(B) of a patient with
hypertensive
chorioretinopathy shows
macular edema and serous
retinal detachments. These
serous retinal detachments
improved after medical
management of hypertension.

19. Differential diagnoses for hypertensive
chorioretinopathy includes
• Diabetic retinopathy, radiation
retinopathy, anemia and other
blood dyscrasias, ocular
ischemic syndrome, and
retinal vein occlusion.
• Clinical history and the
presence of elevated blood
pressure are valuable for
distinguishing hypertensive
chorioretinopathy from other
conditions.

20. Complications
Vascular Risks: Hypertension increases susceptibility to retinal artery/vein
occlusions and arterial macroaneurysms.
Ischemic Effects: Vascular blockages lead to ischemia, prompting
neovascularization, hemorrhage, membrane formation, and retinal detachment.
Diabetic Progression: Hypertension exacerbates diabetic retinopathy
advancement.
Optic Neuropathy: Hypertensive optic neuropathy results in chronic papilledema,
optic atrophy, and severe vision loss.
Glaucoma Link: Hypertension raises the risk of glaucoma; 'proliferative
hypertensive retinopathy' is a newly coined term.

21. Management of hypertensive retinopathy and
choroidopathy
Approach for management: Focus on lowering systemic blood pressure and treating underlying
medical conditions.
Screening recommendation: Routine screening not needed for asymptomatic systemic
hypertension patients.
Action for mild/moderate signs: Patients with mild/moderate hypertensive retinopathy should be
referred to a Internal medicine specialist.
Urgent cases: Severe hypertensive retinopathy requires immediate blood pressure check and
referral to the emergency room.
Collaborative care: ophthalmologists and Internal medicine specialist should work closely for
effective treatment.

22. Take Home Massages
Patients with severe hypertensive retinopathy and arteriosclerotic
changes are at increased risk for coronary disease, peripheral vascular
disease, and stroke.
Since arteriosclerotic changes in the retina do not regress, these
patients remain at increased risk for retinal artery occlusions, retinal
vein occlusions, and retinal macroaneurysms.
Most retinal changes secondary to malignant hypertension will
improve once blood pressure is controlled but AV changes and
arteriolar narrowing will remain.
Damage to the optic nerve and macula, however, could cause long
term reductions in visual acuity.