Opthalmology topic Hypertensive Retinopathy

1. SHIBIN V A

2.  The changes that occur in the fundus of a hypertensive patient.
 Includes
. Retinopathy
. Choriodopathy
. Optic neuropathy

3. NORMAL FUNDUS

4.  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

5. Vasoconstriction
. Renal arterioles
.Choroidal vessels
. Peripapillary choroid
Arteriosclerotic changes
Increased vascular permeability

6. CLINICAL TYPES
CHRONIC
HYPERTENSIVE
RETINOPATHY
MALIGNANT
OR
ACUTE
HYPERTENSIVE
RETINOPATHY

7.  Usually Asymptomatic
 Clinical situations are classified into
. Hypertension with involuntary (senile) sclerosis
- Old age (>50 years)
- Augmented arteriosclerotic retinopathy
. Chronic Hypertension with compensatory arteriolar sclerosis
-Young patients with prolonged HTN & associated with
benign Nephrosclerosis
-Proliferative and fibrous changes of media and results in
chronic glomerulonephritis
-Advanced fundus changes – Albuminuric or Renal retinopathy.

8.  Generalized arterial narrowing
- Vasoconstrictive change
Diffuse vasospasm Increase in BP Increase in renal
arteriolar tone
- Sclerotic change
Intimal thickening Hypoplasia of Hyaline
tunica media degeneration

9.  Focal arteriolar thickening
- Localized vasoconstriction on the disc
- Within ½ disc diameter of its margin zone
 Arteriovenous Nicking
- Arterioles crosses and compresses the vein
- Salu’s sign – Deflection of veins at the AV crossings
- Bonnet’s sign – Banking of veins distal to AV crossings
- Gunn sign – Tapering of veins on either side of the crossings

10.  Arteriolar reflex changes
. Bright and thin, linear blood reflex – Normal
. More diffuse and less bright reflex – Grade I & Grade II
. Copper wiring – Grade III
. Silver wiring – Grade IV

11.  Superficial Retinal haemorrhage ( Flame shaped)
- seen on Posterior pole due to disruption of the capillaries in the retinal nerve
fibre layer
 Hard exudates
- Lipid exudates in the outer plexiform layer of retina due to leaky capillaries
in severe HTN retinopathy.
-Yellow waxy spot with sharp margins
 Cotton Wool spots
- Fluffy white lesions due to areas of infarct in nerve fibre layer

13.  Rapid progression to a serious degree in patients with relatively young
arterioles undefended by fibrosis, and associated with renal insuffciency
- Generalized oedema clouds the retina particularly accentuated at the
disc
-Multiple cotton wool patches
-Hard exudates are profuse and form large masses among which a
macular star is often prominent.
- Vision is seriously affected
-Prognosis is grave unless HTN is controlled

14.  Changes in fundus
-Acute Hypertensive retinopathy
.Arteriolar Narrowing
.Superficial retinal haemorrhages
.Microaneurysms
.Cotton wool spots
- Acute Hypertensive Choroidopathy
. Focal retinal pigment epitheliopathy
. Elschnig’s spots
. Siegrist streaks
. Serous neurosensory retinal detachment
- Acute Hypertensive Optic neuropathy
. Disc oedema, Hemorrhage of disc & peripappilary retina
. Disc Pallor
Cotton wool spots

15. Siegrist streaks

16.  Keith and Wanger Classification
 Scheie Classification
 Wong and McIntosh Classifiction

17. GRADES CLINICAL SYMPTOMS
GRADE I
Mild generalized arteriolar attenuation,
Broadening of arteriolar light reflex
vein concealment
GRADE II
Marked generalized narrowing and focal attenuation of arterioles
Deflection of veins at AV crossings (Salu’s sign)
GRADE III
GRADE II + Copper wiring of arterioles, cotton wool spots
hard exudates & flame-shaped haemorrhages
Bonnet’s sign
Gunn’s sign
Salu’s sign
GRADE IV GRADE III + Silver wiring of arterioles & Pappiloedema

20. GRADE TREATMENT
MILD HYPERTENSIVE RETINOPATHY Blood Pressure control
MODERATE HYPERTENSIVE RETINOPATHY
(With Retinal Haemorrhages, microaneurysms
& Cotton wool spots)
Blood Pressure + Cholesterol management
(assess CV risk factors)
ACCELERATED HYPERTENSIVE
RETINOPATHY
(Bilateral disc swelling)
Small step wise control of BP
(sudden lowering can result in Stroke)

21.  Retinal changes
BP > 160/100 mm of Hg
>200/130 mm of Hg – Marked
. Narrowing of nasal arterioles
. Severe persistent spasm of vessels
. Retinal oedema & exudation
. Retinal detachment is a complication
. Good Prognosis for reattachment

22.  Changes are reversible and disappear after the delivery unless Organic
vascular disease is established
 Pre organic stage – Conservative treatment
 Advent of Hypoxic retinopathy
. Cotton wool spots, retinal oedema & haemorrhage
- Termination of Pregnancy is indicated
. May lead to permanent visual loss or even loss of life of both mother &
child.

23. THANK YOU