5. 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)
6.
7.
8.
9. 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
10. • 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
13. Diagnosis
• Diagnosis is made by
thorough history of the
patient, ophthalmoscopy
(direct or indirect) and also
physical examination.
• History
– May reveal decrease of
patient vision, occipital
headache and high blood
pressure.
• Physical examination
– May detect elevation of blood
pressure
• Ophthalmoscopy
– Show changes in
arteriovenous crossings
– Cotton-wool spot
– Flame haemorrhage
– Silver wire appearance of
narrowed arterioles
– Nicking of veins where
arteries cross them
(arteriovenous nicking)
– Hard exudates “lipids
deposites”
– “Macular star”
– Flame shape haemorrhage
– Retinal oedema
– Swelling of the optic nerve
– Aterial microaneurysms
– Arteriolar macroaneurysms
15. Management
• A major aim of treatment is to prevent, limit,
or reverse such target organ damage by
lowering the patient's 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
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; intraretinal hemorrhages; 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.
