This lecture is based on medical students those are preparing for postgraduate degree namely FCPS/MS/MD/ any any subject coz hypertension is a systemic disease and by seeing the ocular fundus we can asses the general condition of blood vessels in major organ.

1. Hypertension and ocular changes
Dr. Md. Anisur Rahman (Anjum)
Professor & Head, Department of Ophthalmology
Dhaka Medical College, Dhaka

2. Hypertension and ocular changes

3. Is there any blood vessels in the body that you can
see without invasive procedure?

4. But How?

5. So, eye is called “gateway of medicine”

6. So, clinicians have to know how to
perform ophthalmoscopy
To know ophthalmoscopy is nothing, but practice,
practice and practice

9. 1) Arteries differ in color from veins;
Artery is lighter in colour than vein.
2) Arteries are thinner than
adjacent veins ratio A:V = 2:3
3) The central reflex is wider
in arteries than in comparably
sized veins

10. A retinal image showing the retinal artery (red) and vein
(blue) and measured caliber (cross-sectional lines)

11. Ocular changes in hypertension

12. The vascular changes associated with systemic elevated blood pressure
are visible in the retina as hypertensive retinopathy
What are the changes?

13. Pathogenesis of hypertensive retinopathy
3 Factors play role :
 VASOCONSTRICTION
 ARTERIOSCLEROTIC CHANGES
 INCREASED VASCULAR PERMEABILITY

14. Vasoconstriction
BP

15. Arteriosclerotic changes
Manifest as changes in
 arteriolar reflex
A-V nipping
Thickening of
vessels wall

16. Increased Vascular Permeability-
HYPOXIA
 Haemorrhages
Exudates
Focal Retinal Oedema

17. STAGE 1
 SLIGHT NARROWING
&
 SCLEROSIS OF THE VESSELS

18. STAGE 2
 MARKED SCLEROSIS
 WIDENING OF LIGHT REFLEX
 ARTERIOVENOUS NICKING
 GENERALIZED OR FOCAL NARROWING OR BOTH

19. STAGE 3
 RETINAL EDEMA
 LIPID EXUDATION
 COTTON WOOL SPOTS
 HEMORRHAGES

20. STAGE 4
 STAGE 3
 +
 Papilledema (Disc oedema)

21.  Poor reliability and reproducibility
 Grades do not correlate with severity of hypertension
 Not sequential in nature
 Grades do not correlate with prognosis,
cardiovascular events, and mortality.

22. SCHEIE-CLASSIFICATION
(Arteriosclerotic Changes)
• STAGE 1 LIGHT REFLEX & AV NICKING
• STAGE 2 MORE PRONOUNCED STAGE 1
• STAGE 3 COPPER WIRING
• STAGE 4 SILVER WIRING

23. (Arteriosclerotic Changes)
SILVER
WIRING
COPPER
WIRING
LIGHT REFLEX & AV NICKING
MORE PRONOUNCED STAGE 1

25. COPPER
WIRING
of
arterioles
Hyaline thickening & lipoidal infiltration of the intima & media with
An increase in the reflected light reflex & indentation of the venous blood
Column at arteriovenous column

26. SILVER
WIRING
of
arterioles

27. SCHEIE-CLASSIFICATION (Hypertensive Changes)
STAGE 1: SLIGHT ARTERIOLAR NARROWING
STAGE 2: FURTHER NARROWING WITH LOCALIZED
IRREGULARITY & FOCAL CONSTRICTION
STAGE 3: NARROWING + PRESENCE OF LIPID EXUDATION
COTTON WOOL SPOTS & HEMORRHAGES
STAGE 4: NARROWING, EXUDATION, HEMORRHAGES, DISC
EDEMA

29. Chronic hypertension stiffens and thickens arteries. At AV crossing
points (arrow) arteries indent and displace veins.
A
V
NICKING

30. Venous compression at arteriovenous crossing

31. 1- SALU’S SIGN
Deflection in the course of the vein at the Arterio-venous crossing
3 Important Signs
Sign: 1 Salu’s sign

32. 3 Important Signs
Signs 2: GUNN’S SIGN
2- GUNN’S SIGN
Concealment of the vein beneath the artery
at the Arterio-venous crossing

33. 3- BONNET’S SIGN
Venous banking distal to A-V crossing
3 Important Signs
Signs 3: Bonnet’s sign

35. • Small round dark red dots on retinal surface
Best detected on FFA.
• Beginning as dilations in areas in capillary wall
where pericytes are absent
• Initially they are thin walled & Later endothelial
cells proliferate & lay down layers of basement
membrane material around themselves.
• ↑in number as the degree of retinal involvement
• ↑capillary occlusion – retinal ischemia
Microaneurysms

36. COTTON
WOOL
SPOT
Cotton wool spots result from occlusion of retinal pre-capillary
arterioles ( ISCHEMIA) supplying the nerve fiber layer with
concomitant swelling of local nerve fiber axons. Also called "soft
exudates" or "nerve fiber layer infarctions" they are white, fluffy lesions
in the nerve fiber layer.

37. Cotton wool spots (other name is soft
exudate)
 They appear as fluffy white patches
on the retina at the tip of the nerve
fiber layers.
 They are caused by damage to nerve
fibers due to ischaemia
 and are a result of accumulations
of axoplasmic material within
the nerve fiber layer.
Cotton wool spots

38. • Hemorrhages occurs superficially in the
Nerve fiber layer
• Streak appearance - FLAME shaped
hemorrhages – macular edema & subsequent
vision loss
• It’s a result of chronic hypertensive damage
to the capillary wall endothelium
• extravasation of plasma from lumen into the
extra capillary space
Hemorrhages

39. EXUDATES
Exudates occur later in the course of disease,
surrounding areas of hemorrhage, as a result
of lipid accumulation.

40. Hard exudates
(Intra-retinal lipid exudates)
Yellow deposits of lipid and protein within the sensory retina.
Accumulations of lipids leak from surrounding capillaries and
microaneurysms,

41. MALIGNANT HYPERTENSION: Arteriolar
Constriction
Focal Generalized Extravascular Signs Arteriolosclerosis (A-V changes)
Flame-shaped retinal
haemorrhages
Cotton-wool spots
and macular star
Disc oedema

42. GRADE
SIMPLIFIED CLASSIFICATION
FEATURES
MILD
(Retinal Arteriolar Signs)
Generalized Arteriolar narrowing, focal
arteriolar narrowing, AV nicking, copper
wiring or a combination of these
MODERATE
(Retinopathy like lesions) Retinal hemorrhages, micro aneurisms, cotton
wool spots, hard exudates or a combination of
these signs
MALIGNANT
Signs of moderate retinopathy with disc edema

43. MILD

44. MODERATE

45. MALIGNANT

46. RETINOPATHY GRADE SYSTEMIC
ASSOCIATIONS
MANAGEMENT
MILD Weak associations with
stroke, coronary heart
dis. & cardiovascular
mortality
Routine care
Close monitoring of
vascular risk
MODERATE Strong associations with
stroke, coronary heart
dis. & cardiovascular
mortality
Exclude diabetes
Close monitoring of
vascular risk
Possible indication for
hypertension t/t & other
risk factors
MALIGNANT Associated with mortality Urgent Hypertension t/t
CLINICAL MANAGEMENT