1. The cardinal funduscopic feature of malignant hypertension is disk swelling, which appears as blurring and elevation of disk margins. The top image also shows a characteristic star-shaped macular lesion caused by leaking retinal vessels; the bottom image also shows a characteristic flame-shaped hemorrhage and dilated veins.2.Moderate hypertensive retinopathy is characterized by thinned, straight arteries; intraretinalhemorrhages; and yellow hard exudates (top). Cotton-wool spots (bottom) are an additional feature of moderate hypertensive retinopathy. They are caused by focal axonal swelling of the retinal nerve fiber layer as a result of small-vessel occlusion.
Retinal arteriolar narrowing due to thickening and opacification of arteriolar walls (copper wiring) caused by hypertensive arteriosclerosis. Image also shows macular edema.
Hypertensive Retinopathy Nabilah Ayob 060100814 Group H4
Definition• What is Hypertensive Retinopathy?• Hypertensive retinopathy is retinal vascular damage caused by hypertension.
Pathophysiology Arteriosclerosis Systermic and Narrowing of chronic atherosclerosis retinal arterioleshypertension predominates Increased Retinal Hypoxia capillary Ischaemia permeability Focal Retinal Oedema, retinalhaemorrhage,cotton wool spots, hard exudates
Clinical Manifestation• Most patients are asymptomatic.• Some present with headaches and blurred vision.• On ophthalmoscopy : – Generalized arteriolar narrowing – Changes of the arterovenous crossings – Flame haemorrhage – Microaneurysms – Exudates – Arteriolar macroaneurysms – Cotton-wool spots – Optic disc swelling – FIPT ( Focal Intraretinal Periarteriolar Transudates)
Classification• Keith-Wagener-Barker classification Grade Description Grade 1 Slight narrowing, sclerosis, and tortuosity of the retinal arterioles; mild, asymptomatic hypertension Grade 2 Definite narrowing, focal constriction, sclerosis, and AV nicking; blood pressure is higher and sustained; few, if any, symptoms referable to blood pressure Grade 3 Retinopathy (cotton-wool patches, arteriolosclerosis, hemorrhages); blood pressure is higher and more sustained; headaches, vertigo, and nervousness; mild impairment of cardiac, cerebral, and renal function Grade 4 Neuroretinal edema, including papilledema; Siegrist streaks, Elschnig spots; blood pressure persistently elevated; headaches, asthenia, loss of weight, dyspnea, and visual disturbances; impairment of cardiac, cerebral, and renal function
• Scheie classification Staging under this system is as follows: Stage 0 - Diagnosis of hypertension but no visible retinal abnormalities Stage 1 - Diffuse arteriolar narrowing; no focal constriction Stage 2 - More pronounced arteriolar narrowing with focal constriction Stage 3 - Focal and diffuse narrowing, with retinal hemorrhage Stage 4 - Retinal edema, hard exudates, optic disc edema The Scheie classification also grades the light reflex changes from arteriolosclerotic changes, as follows : Grade 0 - Normal Grade 1 - Broadening of light reflex with minimal arteriolovenous compression Grade 2 - Light reflex changes and crossing changes more prominent Grade 3 - Copper-wire appearance; more prominent arteriolovenous compression Grade 4 - Silver-wire appearance; severe arteriolovenous crossing changes
Modified Scheie classificationGrade 0 - No changesGrade 1 - Barely detectable arterial narrowingGrade 2 - Obvious arterial narrowing with focal irregularitiesGrade 3 - Grade 2 plus retinal hemorrhages and/or exudatesGrade 4 - Grade 3 plus disc swelling
Diagnosis• Diagnosis is made by • Ophthalmoscopy thorough history of the – Show changes in patient, ophthalmoscopy arteriovenous crossings (direct or indirect) and also – Cotton-wool spot physical examination. – Flame haemorrhage• History – Silver wire appearance of narrowed arterioles – May reveal decrease of patient vision, occipital – Nicking of veins where headache and high blood arteries cross them pressure. (arteriovenous nicking)• Physical examination – Hard exudates “lipids deposites” – May detect elevation of blood – “Macular star” pressure – Flame shape haemorrhage – Retinal oedema – Swelling of the optic nerve – Aterial microaneurysms – Arteriolar macroaneurysms
Management• A major aim of treatment is to prevent, limit, or reverse such target organ damage by lowering the patients high blood pressure.• Lifestyle changes Promote Healthy lifestyle; exercise, healthy foods• Advice patient to reduce the Blood Pressure – Taking the medication accordingly – Referral to medical team
Complications• Complications of hypertensive retinopathy include: • Blindness • Reduce in vision