1. Hypertensive retinopathy refers to changes in the retina due to high blood pressure and includes narrowing of retinal arterioles, arteriovenous nicking, and hemorrhages. 2. It affects around 30% of people with hypertension. Major risk factors include age, family history, obesity, smoking, and stress. 3. Changes are caused by vasoconstriction, arteriosclerotic changes, and increased vascular permeability from hypertension. Hypertensive retinopathy is typically asymptomatic but some people experience blurry vision. Grading systems describe levels of changes from mild to severe involving hemorrhages, exudates, and optic disc swelling. Treatment focuses on blood

1. HYPERTENSIVE RETINOPATHY

2. INTRODUCTION
Systolic BP> 140 mm Hg, diastolic BP>90mm Hg.
• Hypertensive Retinopathy refers to fundus
changes in patients suffering from systemic
hypertension
• Ocular fundus is of paramount importance in
evaluation of systemic vascular disease
• It is the only region of the body in which
physician can directly visualize manifestation of
vascular pathophysiology

4. EPIDEMIOLOGY
• Hypertension affects around 26% of adult
population worldwide
• Prevalence of hypertensive retinopathy is
approx 30% among the hypertensives
• Afro-carribeans have a double relative risk
compared to other population
• Major risk factors include Age, Family history,
Obesity, Smoking, Stress, Alcohol , lifestyle

5. PATHOGENESIS
3 major factors have role:
I .VASOCONSTRICTION:
Primary response to raised blood pressure is
Arterial narrowing, leading to following changes:
(a)Vasoconstriction of retinal arterioles
(b)Vasoconstriction of choroidal vessels: Leads to choroidal
and RPE ischaemia, manifests as Hypertensive
Choroidopathy
(c)Vasoconstriction of Peripapillary choroid: leads to Optic
nerve head ischaemia, manifests as Hypertensive Optic
Neuropathy

6. 2. ARTERIOSCLEROTIC CHANGES:
due to thickening of vessel wall,
(a)Changes in arteriolar reflex
(b)AV nipping
Reflect the duration of Hypertension
3. INCREASED VASCULAR PERMEABILITY:
- Results from hypoxia
- Leads to Haemorrhages, exudates, macular
edema, focal retinal edema, disc edema

8. CLINICAL TYPES
Hypertensive
retinopathy
Chronic
Hypertensive
retinopathy
Acute or
Malignant
Hypertensive
retinopathy

9. CLINICAL FEATURES
• Mostly asymptomatic
• Some complain of headache and blurring of
vision (Bilateral)

11. Chronic Hypertensive Retinopathy
FUNDUS CHANGES:
I .ARTERIOLAR NARROWING:
• Generalized narrowing is difficult to see but
focal narrowing is well appreciated
• Focal narrowing occurs from spasm of local
areas of the vascular musculature

13. ARTERIOVENOUS NICKING
• Arteries and veins share a common adventitious sheath
• At AV crossing. arteries compress the veins

16. ARTERIOLAR REFLEX CHANGES
• Bright and thin, linear blood reflex:
-seen over the surface of arteriole in young.
-due to blood column in arteriole (vessel wall
is almost transparent)
• More diffuse and less bright reflex: - due to
thickening of vessel wall

17. FLAME SHAPED HEMORRHAGES -lll
• Superficial
• occur at posterior pole
• Disruption of capillaries in retinal nerve fibre
layer

18. HARD EXUDATES
• Lipid deposits in outer plexiform layer of
retina
• Usually follows leaky capillaries in severe
disease
• Appear as 'yellow waxy spots' with sharp
margin
• Generally seen in posterior pole

19. COTTON WOOL SPOTS
• Also called 'Soft Exudates'
• White plaques with a hazy, irregular outline.
• They are usually ovoid in shape, variable in
size and number
• Occur in nerve fibre layer of retina result of
capillary infarction

21. OPTIC DISC SWELLING/
PAPILLOEDEMA
• Optic disc edema is a primary manifestation of
hypertensive optic neuropath
• Vasoconstriction and choroidal ischemia in the
setting of malignant hypertension result in
optic disc edema and axoplasmic flow stasis

23. KEITH WAGENER AND BARKER
CLASSIFICATION OF HYPERTENSIVE
RETINOPATHY

24. Grade 1
Generalized narrowing(white arrow) with moderate
opacification of arterioles (black arrow).

25. Grade ll
• Marked generalised narrowing and focal
attenuation of artertioles
• 'Salus' Sign (deflection of veins at AV
crossings)

27. Grade lll
• Retinal arteriolar narrowing + focal constriction
• Prominent AV crossing changes
• Bonnet Sign (banking of veins distal to AV c)
• Gunn Sign (tapering of vein on either side of AV
crossings)
• Flame shaped haemorrhages
• Cotton wool spots
• Hard exudates

31. Grade IV
• Grade III changes
• Papilloedema

33. OTHER CLASSIFICATION
Scheie classification
• Stage 0: 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
haemorrhages S
• Stage 4: Retinal oedema, hard exudates, optic
disc edema

34. Wong and Mcintosh classification
• Mild retinopathy: one or more of the following signs:
generalised arteriolar narrowing, focal arteriolar
narrowing, AV nicking, arteriolar wall reflex
broadening.
• Moderated retinopathy: consists of mild retinopathy
with one or more of the following signs: Retinal
haemorrhages (blot and dot or flame shaped),
microaneurysms, cotton-wool spots, and hard exudates
• Accelerated retinopathy: consists of moderate
retinopathy signs plus optic disc swelling
-may be associated with visual loss

35. MALIGNANT HYPERTENSIVE
RETINOPATHY
• Cause: Rapid progression to a serious degree
in young patient with relatively young
arterioles undefended by fibrosis
• Changes include:
1 . Hypertensive Retinopathy
2.Hypertensive Choroidopathy
3 . Hypertensive Optic Neuropathy

36. ACUTE HYPERTENSIVE
CHOROIDOPATHY
• Elschnig's spots:
Black spots
surrounded by
yellow halos
• Due to clumping
and atrophy of
infarcted pigment
epithelium

38. • Acute focal retinal pigment epitheliopathy
characterized by focal white spots
• Serous neurosensory retinal detachment

39. MANAGEMENT
• MILD: BP control only
• MODERATE: BP control +assessment of risk factors
( eg. cholesterol)
BP monitoring every 3-6 months
If indicated, risk reduction therapy ( cholesterol
reducing agents)
• ACCELERATED: small step wise control of BP, avoid
sudden reduction ( risk of Optic nerve head
hypoperfusion, Stroke)

41. PREGNANCY INDUCED HTN
• Previously called 'Toxemia of Pregnancy’
• Raised BP , proteinuria , generalised edema
• Retinal changes liable to occur when
BP >160/ 100 mm Hg,
marked when BP> 200/130 mm Hg

42. • Earliest changes: narrowing of nasal arterioles
-generalised narrowing
• Persistent spasm of vessels - cotton wool
spots, hemorrhages
• Retinal edema and exudation

43. MANAGEMENT
• Changes are reversible , disappear after delivery
(unless organic cause established)
• Pre- Organic Stage: patient responds well to
conservative treatment, pregnancy continued
under close observation
• Hypoxic Retinopathy: cotton wool spots,
haemorrhages, retinal edema
terminate pregnancy ??

44. THANK YOU