This document discusses hypertensive retinopathy, which is caused by high blood pressure damaging the small blood vessels in the retina. It begins by covering the prevalence of hypertensive retinopathy and associated risk factors. Next, it describes the diagnostic techniques and signs seen during an eye examination, such as arteriolar narrowing, tortuosity, and arteriovenous nicking. The classification of hypertensive retinopathy severity from Grade I to IV is then explained. The document concludes by discussing the pathophysiology, management through blood pressure control, and associated ocular conditions.

1. Hypertensive Retinopathy
Dr. Reena ( SCEH, Lahan )

2. Blood pressure (BP) is the pressure of circulating blood on the
walls of blood vessels. Most of this pressure is due to work done
by the heart by pumping blood through the circulatory system.

4. sphygmomanometer blood pressure machine

7. Hypertensive Retinopathy
• Prevalence
• Symptoms
• Diagnostic techniques and signs
• Pathophysiology
• Associated conditions
• Management

8. Hypertensive Retinopathy -
Introduction
• Bilateral
• Symmetrical
• Small blood vessel disease
• Caused by systemic hypertension
– Acute or chronic
– Systolic or diastolic
• End organ disease manifestation

9. Hypertensive Retinopathy -
Prevalence
• The second most common retinal vascular
disease
• Systemic hypertension (>160/90mmHg) 10-
15% in the UK >40 age group
• Malignant hypertension (240/140mmhg) 0.5-
0.75%
• Hypertensive retinopathy 4-10%

10. Hypertensive Retinopathy –
Prevalence, Risk factors
• Afro-Caribbeans = relative risk factor 2x
• Age
• Family history
• Medications
• Obesity
• Smoking
• Stress
• Alcohol consumption
• Lack of exercise

11. Hypertensive Retinopathy –
Prevalence, Morbidity Risk
• Stroke (7x)
• Heart attack (4x)
• Coronary artery disease (3x)
• Peripheral artery disease (2x)

12. Hypertensive Retinopathy –
History & Symptoms
• Possible history of systemic hypertension
• Systemic hypertension largely
asymptomatic
• Hypertensive retinopathy largely
asymptomatic
• The eye examination will often give the
first clue of systemic hypertension

13. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
• Ophthalmoscopy (non-malignant retinopathy)
– Arteriosclerosis from chronic disease
• focal arteriolar narrowing
• arterio-venous crossing changes
– venous constriction and deflection
– distal banking
• arteriolar colour changes
• vessel sclerosis
– Similar signs with ageing
• Sphygmomanometry
– blood pressure measurement is required to make a
positive diagnosis in the absence of malignant
retinopathy changes

14. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
• Arteriolar Narrowing
– Young patients, autoregulation causes uniform
narrowing of retinal arterioles
– Older patients, arteriosclerosis and autoregulation cause
focal arteriolar narrowing
– Assess the arterio-venous calibre ratio as a percentage
• adjacent arteries and veins
• equivalent numbers of bifurcations
• between 1 and 3 DD from optic disc

15. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
Generalised narrowing of the retinal arterioles

16. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
Focal narrowing of the retinal arterioles –
Copper and Silver Wiring

17. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
• Tortuosity of the retinal arterioles
– not, in itself, a sign of hypertensive retinopathy
– segmental arteriolar tortuosity is such a sign
• commonly found in the nasal retina
– Almost 80% of patients with hypertension do
not show tortuosity
– A standard 5 point grading scale can be used
– Record tortuosity type, severity and location

18. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
• Arteriosclerosis
– Thickening of the arteriolar wall
– Assess using the arteriolar reflex
• brightness
• thickness ratio
– Assess using arterio-venous crossing changes
• venous deflection (Salus’ sign)
• localised venous narrowing (nipping; Gunn’s sign)
• right-angled crossing caused by venous deflection
• venous distal banking (Bonnet’s sign)

19. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
Gunn’s sign &
right-angled crossing
Bonnet’s sign

20. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
Gunn’s sign,
right-angled
crossing &
Bonnet’s sign
Salus’ sign?

21. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
• Malignant Hypertensive Retinopathy
– A:V ratio of 25% & arterial reflex ratio of 60%
• “copper wiring”
– A:V ratio of <20% & arterial reflex ratio of 100%
• “silver wiring”
– cotton wool spots
– hard exudates
– dot and flame shaped haemorrhages
– if advanced – retinal or macula oedema or
papilloedema
– all non-advanced changes due to focal hypoperfusion
– note presence, number, size, position (photograph!)

22. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
Early malignant
Dot and blot haemorrhages
Hard and soft exudates
Diffuse arteriolar
narrowing
Arterio-venous crossing
defects

23. Hypertensive Retinopathy –
Diagnostic Techniques & Signs
Advanced malignant
Macular star
Pailloedema

24. Hypertensive Retinopathy -
Classification
<20%Malignantabnormalities encountered in Grades I
through III, as well as swelling of the optic
nerve head and macular star
IV
25%Malignantabnormalities seen in Grades I and II, as
well as retinal haemorrhages, hard
exudation, and cotton-wool spots
III
33%Non-malignantnarrowing of the retinal arteries in
conjunction with regions of focal
narrowing and arterio-venous nipping
II
50%Non-malignantminimal narrowing of the retinal arteries
I
A:V
ratio
Alternative
description
DescriptionGrade

25. Hypertensive Retinopathy –
Classification Grade 2

26. Hypertensive Retinopathy –
Classification Grade 3

27. Hypertensive Retinopathy –
Classification Grade 4

28. Hypertensive Retinopathy –
Classification
• HR grades I and II are typically chronic
• HR grades III and IV are typically acute
– diastolic blood pressure >= 110 correlates with
grade III
– diastolic blood pressure >= 130 correlates with
grade IV

29. Hypertensive Retinopathy –
Choroidopathy
• Hypertensive choroidopathy frequently occurs
with grade IV Hypertensive Retinopathy
– yellow spots (Elshnig Nodules) are visible at the level
of the retinal pigment epithelium
– hyperfluorescent on fluorescein angiography
– secondary to arteriosclerosis within the choriocapillaris
– in severe cases they cause serous retinal detachment
– resolve to become pigmented or depigmented
– linear groups of spots occur they are referred to as
Siegrist's streaks

30. Hypertensive Retinopathy –
Pathophysiology
• A disease of the retinal microvasculature
• Cholesterol deposition in the tunica intima of
medium and large arteries
– reduction in the lumen size of these vessels
• Arteriolosclerosis causes a breakdown in
autoregulation
– the high pressures in the arterioles are transmitted to
the retinal capillaries
– capillary closure or haemorrhage occurs

31. Hypertensive Retinopathy –
Pathophysiology
• Dot haemorrhages are ruptures of the deep
capillary bed
– leakage of blood into the outer plexiform layer
– their depth leads to a round, small area of blood
– Phagocytosis of the red and white blood cells leaves
hard exudates
– the hard exudates are at a similar depth and have a
similar size (slightly larger) and shape to the dot
haemorrhages
– hard exudates will last for more than 12 months, even
following successful treatment.

32. Hypertensive Retinopathy –
Pathophysiology
• Flame shaped haemorrhages are ruptures of the
superficial capillary bed
– the blood disperses within the retinal nerve fibre layer
• Either capillary rupture or capillary closure gives:
– RGC oxygen starvation
– RGC waste removal failure
– Axoplasmic transport failure
• accumulation of waste material at the boundary between
perfused and non-perfused retina
• clinically visible as cotton wool spots (CWS)
• In extreme cases, disc oedema
– a hypertension-related increase in intracranial pressure

33. Hypertensive Retinopathy –
Pathophysiology
• Arteriosclerotic changes persist after Tx
• Hypertensive retinopathy changes resolve over time
following Tx
– Cotton wool spots develop in 24 to 48 hours with the elevation
of blood pressure, and resolve in 2 to 10 weeks
– A macular star develops within several weeks of the
development of elevated blood pressure and resolves within
months to years
– Papilloedema develops within days to weeks of increased blood
pressure and resolves within weeks to months
– Visual recovery is limited if the macula or optic nerve have been
affected

34. Hypertensive Retinopathy –
Management
• Appropriate treatment of the underlying
hypertension
• If the patient is previously undiagnosed the patient
needs referral to their general practitioner for
assessment
• A grade I or grade II hypertensive retinopathy
– non-urgent referral
• A grade III hypertensive retinopathy
– more urgent referral to the GP
• A grade IV hypertensive retinopathy
– Px is in medical crisis. This patient needs immediate
referral to a hospital eye casualty department

35. Hypertensive Retinopathy –
Associated Conditions
• Branch retinal artery occlusion (BRAO)
• Central retinal artery occlusion (CRAO)
• Branch retinal vein occlusion (BRVO)
• Central retinal vein occlusion (CRVO)
• Non-arteritic anterior ischaemic optic
neuropathy (NAION)

36. Hypertensive Retinopathy –
Clinical Pearls
• If CWS are present, autoregulation has
failed: diastolic BP >110mmHg
• Papilloedema means malignant
hypertension
BP > 250/150mmHg
• Fluorescein angiography is not indicated as
it provides no diagnostic information

37. Hypertensive Retinopathy –
Clinical Pearls
Wet retina:
multiple haemorrhages
extensive oedema
multiple exudates
few cotton wool spots
rare flame-shaped
haemorrhages
visibly abnormal retinal
veins and capillaries
Dry retina:
few haemorrhages
rare oedema
rare exudate
multiple cotton wool spots
flame-shaped
haemorrhages
visibly abnormal retinal
arteries
Hypertensive Retinopathy Diabetic Retinopathy