Sunir Garg

BASICS

DESCRIPTION

Systemic hypertension leads to characteristic changes in the retina, choroid, and optic nerve. It can be divided into acute and chronic findings

Pregnancy Considerations

In women of child-bearing age with uncontrolled hypertension, check pregnancy status as these patients may have eclampsia/pre-eclampsia.

EPIDEMIOLOGY

Incidence

• 6.0% of patients in Beaver Dam Eye Study developed hypertensive retinopathy (1).

– Arterial narrowing was seen in 9.9% of patients.

– AV nicking was observed in 6.5% of patients (1).

Prevalence

• Occurs in 2–15% of people older than 40 years of age.

• Greater in African American than Caucasian population.

• No reliable association with age or gender (2).

RISK FACTORS

• Elevated systolic and diastolic blood pressure.

• Diabetes.

Genetics

There are likely multiple genetic factors that play a role in the development of hypertension.

GENERAL PREVENTION

• Maintenance of normotensive blood pressure.

• Antihypertensive medication.

• Regular blood pressure monitoring.

PATHOPHYSIOLOGY

• As blood pressure rises, retinal blood vessels undergo vasoconstriction.

• Over time, the blood vessel walls thicken.

• The blood–retinal barrier becomes compromised, leading to exudation and ischemia.

ETIOLOGY

• Essential hypertension

• Hypertension secondary to eclampsia, renal artery stenosis, and other systemic conditions

COMMONLY ASSOCIATED CONDITIONS

• Diabetes

• Hyperlipidemia

• Atherosclerosis

• Retinal artery macroaneurysm

• Branch vein or artery occlusion

• Stroke

• Cognitive decline

• Possible increased risk of coronary artery disease

• Age-related macular degeneration—possible link

• Glaucoma—possible link

DIAGNOSIS

HISTORY

• May or may not have diagnosis of hypertension/ elevated blood pressure.

• Many will have no history of eye disease.

PHYSICAL EXAM

• Findings from acute, accelerated or malignant, hypertension

– Fibrinoid necrosis of choroid/retinal pigment epithelium causes a deep, yellow – gray whitening in the acute phase

– Later these areas become hyperpigmented and are called Elschnig spots. Hyperpigmented flecks that are arranged in a linear fashion (following areas of choroidal infarction) are called Siegrist streaks.

– Optic disc edema—this can result from ischemia to the optic nerve to intracranial hypertension. must be present for diagnosis of malignant hypertension.

– Retinal hemorrhages, which may be ranging from mild intraretinal hemorrhages to severe subinternal limiting mimbane or subretinal hemorrhage

– Cotton wool spots

– Serous retinal detachment (4).

• Findings from chronic hypertension.

– Arteriolar narrowing—decreased artery to vein ratio (normal is 2:3).

– Copper wiring—light reflex widens and the vessel takes on the appearance of copper wire.

– Silver wiring occurs when the vessel becomes so narrow that blood flow through the artery is not visible on ophthalmoscopy.

– Arterior–venous nicking occurs when the artery compresses the vein in their common adventitial sheath (Gunn sign).

– Vein may be deflected as it crosses the arteriole (Salus sign).

– Microaneurysms

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Initial lab tests

Blood pressure measurement.

Follow-up & special considerations

In patients with diabetes, controlling blood pressure decreases the risk of progression of retinopathy (3).

Imaging

Initial approach

• None needed unless secondary cause of blood pressure elevation is suspected.

• Fluorescein angiography may demonstrate microaneurysms, retinal telangiectasias, retinal/choroidal ischemia, and diffuse capillary and/or optic nerve leakage.

Follow-up & special considerations

• Close monitoring of both systolic and diastolic blood pressure is essential.

• Many acute changes may resolve with treatment of blood pressure.

Pathological Findings

• The Scheie classification of hypertensive retinopathy is the following:

– Grade 0: Normal fundus

– Grade 1: Mild arteriolar narrowing

– Grade 2: Obvious arteriolar narrowing with focal vessel irregularity

– Grade 3: Grade 2 with exudates or hemorrhages

– Grade 4: Grade 3 with optic disc edema

DIFFERENTIAL DIAGNOSIS

• Diabetic retinopathy

• Radiation retinopathy

• Juxtafoveal telangiectasis

• Retinal artery occlusions

• Vasculitis (lupus, lyme disease, sarcoidosis)

• Giant cell arteritis

TREATMENT

MEDICATION

First Line

Oral antihypertensive medications.

Second Line

Intravenous antihypertensive medication.

ADDITIONAL TREATMENT

General Measures

Treatment should be initiated with direction from the primary care physician.

Issues for Referral

• All patients with suspected hypertensive retinopathy should be referred to their primary doctor for further workup and treatment.

• Patients with signs of malignant/acute hypertension may require emergency inpatient stabilization.

IN-PATIENT CONSIDERATIONS

Initial Stabilization

Blood pressure lowering medications (see earlier).

Admission Criteria

Hypertensive emergency/malignant hypertension (diastolic blood pressure >120, with end-organ damage, which includes optic disc edema.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Blood pressure should be closely monitored by the primary care doctor.

• Patients should undergo regular dilated fundus examination to rule out the above complications.

DIET

For salt-responsive patients, diets low in salt may aid in blood pressure lowering.

PATIENT EDUCATION

Inform patients of the need to maintain a normotensive blood pressure and to regularly take their blood pressure medications to reduce their risk of visual complications.

PROGNOSIS

Patients who maintain their blood pressures at a normotensive level, with drugs, diet or otherwise, usually maintain excellent vision.

COMPLICATIONS

• Retinal vein occlusion

• Retinal artery macroaneurysm (women > men)

• Retinal arterial occlusion

• Optic nerve ischemia/neuropathy

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