3. INTRODUCTION
• Hypertensive retinopathy refers to fundus changes occurring in
patient suffering from systemic hypertension.
• Uncontrolled systemic hypertension leads to non-perfusion at
various retinal levels and to neuronal loss and related scotomata.
4. INTRODUCTION CONT…
• It is usually Bilateral and Symmetrical
• Small blood vessel disease caused by systemic hypertension
Acute or chronic
Systolic or diastolic
• End organ disease manifestation
6. PREVALENCE
• The second most common retinal vascular disease
• Systemic hypertension (>160/90mmHg) 10-15% of cases in UK with
>40 years
• Malignant hypertension (240/140mmhg) 0.5-0.75%
• Hypertensive retinopathy 4-10%
7. • In Africa the prevalence rate of HTN is 33% and in Kenya
the prevalence rate of HTN is 26%.
• There is paucity of data in sub-saharan Africa
• Prevalence in kenya 2018 (MTRH) was at 23.3% ; 84 %
grade 1 ,13% grade 2 , 3 % had grade 3.
8. RISK FACTORS
• Afro-Caribbeans = relative risk factor 2x
• Age
• Family history
• Obesity
• Smoking
• Stress
• Alcohol consumption
• Lack of exercise
9. PATHOGENESIS
Factors which play role in the pathogenesis of hypertensive retinopathy include:
1. Vasospasm
narrowing of arteries in the primary response to raised blood pressure and is related
to the severity of hypertension.
Vasospasm of retinal arterioles occurs in pure form in young individuals, but is
affected by the pre-existing involutional sclerosis in older patients.
Vasospasm of choroidal vessels causes choroidal and RPE ischaemia, resulting to
hypertensive choroidopathy.
Vasospasm of peripapillary choroid leads to optic nerve head ischaemia, manifesting
as hypertensive optic neuropathy.
11. 2. ARTERIOSCLEROTIC CHANGES
• Manifest as changes in the arteriolar reflex and A-V nipping result from
thickening of the vessel wall and are a reflection of the duration of hypertension
(chronic hypertension).
• In older patients, arteriosclerotic changes may pre-exist due to involutional
sclerosis.
12. 3. INCREASED VASCULAR PERMEABILITY.
• Results from hypoxia causing breakdown of inner blood
retinal barrier and occurs in severs hypertension
• Is responsible for haemorrhages, exudates, focal retinal
oedema, macular oedema, focal intraretinal periarterial
transudates (FlPTs), and disc oedema.
14. 4. RAISED INTRACRANIAL PRESSURE
• Occurs in malignant or accelerated hypertension
• manifests as hypertensive optic neuropathy, characterized
by papilloedema and optic nerve ischemia.
19. FUNDUS CHANGES OF CHRONIC HYPERTENSIVE
RETINOPATHY
1. Generalized arterial narrowing - consists of vasoconstrictive phase due to
vasospasm and sclerotic phases due to intimal thickening, hypoplasia of tunica
media and hyaline degeneration.
20. FUNDUS CHANGES OF CHRONIC HYPERTENSIVE
RETINOPATHY CT
2 Focal arteriolar narrowing is seen as areas of localized vasoconstriction on the
disc.
21. FUNDUS CHANGES OF CHRONIC HYPERTENSIVE
RETINOPATHY CT
3 Arteriovenous nicking is the hallmark of hypertensive retinopathy and occurs
where arteriole crosses and compresses the vein.
22. FUNDUS CHANGES OF CHRONIC HYPERTENSIVE
RETINOPATHY CT
4. Arteriolar reflex changes. The normal light reflex of the retinal vasculature is
formed by the reflection from the interface between the blood column and vessel
wall.
23. FUNDUS CHANGES OF CHRONIC HYPERTENSIVE
RETINOPATHY CT
5 Superficial retinal hemorrhages (flame-shaped) occur at the posterior pole due to
disruption of the capillaries in the retinal nerve fibre layer.
24. FUNDUS CHANGES OF CHRONIC HYPERTENSIVE
RETINOPATHY
6. Hard exudates are lipid deposits in the outer pleixform layer of retina which occur
following leaky capillaries in severe hypertensive retinopathy. They appear as
yellowish waxy spots with sharp margins.
25. FUNDUS CHANGES OF CHRONIC HYPERTENSIVE
RETINOPATHY CT
• 7. Cotton wool spots - fluffy white lesions and represent the areas of infarcts in
the nerve fibre layer, due to ischemia
26. MALIGNANT HYPERTENSION
• Expression of hypertension rapid progression to a serious degree in a patient with
relatively young arterioles undefended by fibrosis.
• Marked arteriolar narrowing
• Papilloedema
27. MALIGNANT HYPERTENSION
• Retinal edema over posterior pole
• Superficial flame shaped haemorrhages
• Abundance of cotton wool patches
28. ACUTE HYPERTENSIVE CHOROIDOPATHY
• It is primarily due to choroidal ischemia, which produces ischaemic damage to the
overlying retinal pigment epithelium
• Fundus changes include:
1. Acute focal retinal pigment epitheliopathy - characterised by focal white spots,
occurs due to acute ischaemic changes in choriocapillaries
29. ACUTE HYPERTENSIVE CHOROIDOPATHY CT
2 :Elschnig's spots - small black spots surrounded by yellow halos, due to clumping
and atrophy of the infarcted pigment epithelium.
30. ACUTE HYPERTENSIVE CHOROIDOPATHY CT
3. Siegrist streaks - formed due to linear configuration of the pigment along the
choroidal arterioles. These are formed due to fibrinoid necrosis associated with
malignant hypertension.
31. ACUTE HYPERTENSIVE CHOROIDOPATHY CT
4. Serous neurosensory retinal detachment - affects the macular area, may occur
due to accumulation of fluid beneath the retina following breakdown of outer
blood-retinal barrier owing to ischemic damage.
32. ACUTE HYPERTENSIVE OPTIC NEUROPATHY
Changes include:
• Disc oedema and haemorrhages on the disc and peripapillary retina due to
vasoconstriction of peripapillary choroidal vessels supplying the optic nerve head.
• Disc pallor, of variable degree, may occur late in the course of disease.
33. RETINOPATHY IN PREGNANCY-INDUCED
HYPERTENSION
• Pregnancy-induced hypertension (PIH), previously known as 'toxaemia’ of
pregnancy; is a disease of unknown etiology
• Characterised by raised blood pressure, proteinuria and generalised oedema.
• Retinal changes in PIH – occur in BP above 160/ 100 mm of Hg and are marked
BP rises above 200/ 130 mm of Hg.
34. RETINAL CHANGES IN PIH
• Earliest changes - narrowing of foveal and nasal arterioles, followed by
generalised narrowing.
• Severe persistent spasm of vessels – Cause retinal hypoxia characterised by
appearance of 'cotton wool spots' and superficial haemorrhages.
• progression of retinopathy occurs rapidly if pregnancy is allowed to continue and
changes of hypertensive opticn neuropathy and acute choroido pathy (Elschnig
spots and other RPE lesions) can occur.
35. RETINAL CHANGES IN PIH
• Retinal oedema and exudation is usually marked.
• Rarely, bilateral exudative retinal detachment.
• Prognosis for retinal reattachment is good, as it occurs spontaneously within a
few days of termination of pregnancy.
37. MANAGEMENT OF PIH
• Retinal changes disappear after delivery unless organic vascular disease occurs
• Pre organic stage- manage as pregnancy continues
• Advanced hypoxic retinopathy-soft exudates, retinal edema and hemorrhages- terminate
the pregnancy
38. HISTORY AND 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
39. DIAGNOSIS
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
40. CONT..
• Sphygmomanometry
• Blood pressure measurement is required to make a positive diagnosis in the absence of
malignant retinopathy changes
45. MANAGEMENT
1). Control Systemic Hypertension
• Life style modification to control systemic HTN
• Drugs to reduce systemic HTN
2) Hypertensive Retinopathy with visual threatening complications
e.g retinal edema
• With laser therapy
• Intravitreal injection of vascular endothelial growth factors(VEGF)
46.
47. REFFERENCES
• American Academy of ophthalmology
• Comprehensive Ophthalmology 9th Edition A K Khurana
• Kanski 9th Edition Clinical Ophthalmology.
48. • Magara, G. M. (2022). Prevalence of Uncontrolled Hypertension and Associated Factors among Hypertensive Patients
Attending Medical Outpatient Clinic, Thika Level 5 Hospital, Kiambu County, Kenya (Doctoral dissertation, JKUAT-
COHES).
• Rakwach, M. O. (2021). Prevalence and risk factors for hypertensive retinopathy at Moi Teaching and Referral
Hospital, Eldoret, Kenya (Doctoral dissertation, Moi University).
