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Hypertensive retinopathy
- 2. Hypertensive Retinopathy • Fundus changes that occur in patients with severe hypertension • Clinical presentation includes changes of -Retinopathy -Choroidopathy -Optic neuropathy
- 3. pathogenesis • 3 factors play role in pathogenesis 1. Vasoconstriction 2. Arteriosclerotic changes 3. Increased vascular permeability
- 4. Pathophysiology Systemic chronic hypertension Arteriosclerosis Narrowing of retinal arterioles Retinal Ischaemia Hypoxia Increased capillary permeability Focal Retinal Oedema, retinal haemorrhage,cotton wool spots, hard exudates
- 5. Clinical types Clinically hypertensive fundus changes can be described as • Chronic hypertensive retinopathy • Malignant/acute hypertensive retinopathy
- 6. Chronic hypertensive retinopathy • Usually asypmtomatic • Clinical situations include 1. Hypertension with involutinary ( senile) sclerosis: elderly patients (> 50 yrs ),fundus changes comprise augmented arteriosclerotic retinopathy.
- 7. 2.Chronic hypertension with compensatory arteriolar sclerosis • Seen in young individuals • young arterioles respond to HTN by prolifrative and fibrous changes in media • In the kidneys there will be chronic glomerulonephritis • so known as albuminuric or renal retinopathy
- 9. Fundus Changes • Generalized arteriolar narrowing • Focal arteriolar narrowing • A-V nicking -hallmark of HR
- 10. • Salu’s sign – deflection of veins at A-V crossing • Bonnet sign – banking of veins distal to A-V crossing • Gunn sign – tapering of veins on either side of crossing
- 11. • Arteriolar Reflex Changes -bright, thin, linear reflex –Normal -diffuse, less bright reflex –Grade I/II -Copper wiring -Silver wiring
- 12. • Superficial retinal haemorrhages • Hard exudates • Cotton wool spots
- 13. Malignant hypertension • rapid progression of the hypertensive state in a patient with relatively young arterioles undefended by sclerosis • There will be retinopathy , choroidopathy & optic neuropathy • It is asso. With renal insufficiency
- 15. Choroidopathy • Elschnig’s spots- focal areas infarcted retinal pigment epithelium • Siegrist streaks- due to fibrinoid necrosis in malignant hypertension
- 16. Grade I Mild generalised arteriolar attenuation Broadening of arteriolar light reflex Vein concealment
- 17. Grade II Marked generalised narrowing and focal attenuation of artertioles Salus’ Sign (deflection of veins at AV crossings)
- 18. Grade III Copper wiring of arterioles Bonnet Sign (banking of veins distal to av crossings) Gunn Sign (tapering of vein on either side of av crossings) Flame shaped haemorrhages, Cotton wool spots Hard exudates Gunn SignBonnet sign
- 19. Grade IV Grade III changes Silver wiring of arterioles Papilloedema
- 21. Management Mild HR BP control only Moderate HR BP control + Assess cholesterol levels & if indicated cholesterol lowering agents Accelerated HR Urgent anti hypertensive management by stepwise control of BP over a few hours
- 22. BP >160/100mm Hg- > 200/130mm Hg Narrowing of nasal arterioles- generalised Cotton wool spots; retinal hemmorhages- retinal hypoxia ‘Macular star’ – ‘flat macular detachment’
- 23. Management • Changes are reversible , disappear after delivery • In preorganic stage : conservative treatment , pregnancy is continued under close observation • Advent of hypoxic retinopathy( cotton wool spots,hemorrhages,retinal edema): indication for termination of pregnancy ,otherwise permanent visual loss or even loss of life may occur.