Original Article

Hypertensive retinopathy in a Nigerian community

**CO Omolase, FWACS, FMCOphth*, O Adekanle, FMCP**, BO Omolase, MBBS

Federal Medical Centre, Owo, Ondo State, Nigeria Department of Ophthalmology*, Department of
**Medicine

-** * -** - -

*
**
.

.

.

 2007
. 2008

.

( (11 6 :
1 . 55 4
. 35 10

11 .
.

..

. :

Medical Centre,Owo,Ondo State ,Nigeria.

Methodology The study was conducted
between September
2007 and January 2008.One hundred
consenting hypertensives were interviewed
by the authors using a semi-structured
questionnaire. All the respondents had

_________________________________

of the respondents had good blood pressure

control, 35% had fair blood pressure control
and 10% had poor blood pressure control.
Conclusion Hypertensive retinopathy
occurred in only

11% of patients and more than half of them

were of grade 3. Blood pressure control
affected the prevalence of hypertensive
retinopathy, however, the differences amongst

Correspondent author Dr Omolase Charles

Oluwole Department of Ophthalmology,

Federal Medical Centre, PMB 1053, Owo,
Ondo State, Nigeria Email:
omolash2000@yahoo.com

79 Sudan Med J 2010:46(2)

Abstract This study was designed to

determine the prevalence of hypertensive
retinopathy amongst hypertensives presenting
to the medical outpatient department of
Federal

Original Article Hypertensive

retinopathy CO Omolase

the different
groups were
not
statistically
significant.
There is
need to
ensure that
hypertensiv
es have
regular
ocular
examination
. Physicians
should
ensure
optimal
blood
pressure
control in
hypertensiv
e patients so
as to
prevent
target organ
damage.
Keywords:
Hypertensio
n,
retinopathy,
blood
pressure
control,
Nigeria.
Introductio
n

Hypertensio
n may have
serious

effects on
the
eyes. It
plays an
important
role in a
variety of
ophthalmic
conditions

(1

and is one
of the

most
important
noncommunica
ble
disorders in
(2)

the world .
It affects
approximat
ely onebillion
people
worldwide
and it is the
most

important
modifiable
risk factor
for
(3,4,5)

stroke
.
Hypertensio
n acts as a
silent killer

many years
before overt

end organ
damage was
clinically
(6)

apparent .
The
prevalence
of

retinopathy
10)

hypertensio
n in Nigeria
ranges from
(7)

15-20% .

In addition
to being the
chief cause
of death in
developing
countries,
systemic
hypertensio
n is also a
leading
cause of
visual
impairment

8)

. It is
associated
with a
number of
ocular
conditions
although the
exact causal
relationship
are yet to be
fully
(9)

lar risk by
causing end
organ
damage that
includes

defined .
Hypertensio
n produces
cardiovascu

. The
established
classificatio
n
techniques
for grading
hypertensiv
e
retinopathy
have poor
correlation
with
severity of
hypertensio
(1)

n . Large
population
based
studies
suggest that
fundus
lesions
described in
hypertensiv
e
individuals
may also
occur in
nonhypertensiv
(11-14)

es
.
Poorly
controlled
systemic
hypertensio
n causes
worsening
of micro
vascular

disease of
the eye
similar to
diabetic
(

retinopathy
15-17)

The eye is
an end
arteriolar
system and
is therefore
susceptible
to changes
in blood
pressure.
The eye is
the only
place where
blood
vessels can
be viewed
by non
invasive
techniques

(8

hypertensiv
e
retinopathy,
hypertensiv
e optic
neuropathy
and
hypertensiv
e
choroidopat
hy. The first
and most
widely used
classificatio
n of

hypertensiv
e fundus
changes has
been that of
Keith et
(18)

al . One
of the
limitations
of this

. Recent
studies
revealed
that from
pathogenic
point of
view
various
fundus
lesions in
malignant
hypertensio
n consist of

three
distinct
categories:

classificatio
n is that not
all the cases
fall into one
of the four
defined
categories
9)

(1

Hypertensiv
e
retinopathy
represents
target organ
damage in

patients
with high
systemic
arterial
blood
pressure
and was
first
described
by
Liebreich in
1859.
Sustained
hypertensio
n leads to
disruption
of the
bloodretinal
barrier,
increased
vascular
permeabilit
y and
secondary
arteriosclero
(9)

sis .
Abnormal
vascular
permeabilit
y produces
flame
shaped
haemorrhag
es, retinal
oedema and
lipid
exudates

(20)

In view of
the retinal
changes
associated

with
systemic
hypertensio
n this study
was
designed to
evaluate the
prevalence
of
hypertensiv
e
retinopathy
amongst
hypertensiv
es
presenting
to the
medical
outpatient
of Federal
Medical
Centre,
Owo, Ondo
State,
Nigeria.
Methodolo
gy
Ethical
approval
was
obtained
from
Ethical
Committee
of Federal
Medical
Centre,
Owo prior
to carrying
out this
study. This
study was
conducted
at the eye

clinic of the
hospital
between
September
2007 and
January
2008. The
cases of
cataract and
other
conditions
impairing
the fundal
clarity and
those with
other
systemic
conditions
like
diabetes
mellitus
were
excluded
from the
study.
Patients
were
labeled as
hypertensiv
e when their
blood
pressure
measured at
least twice
during two
separate
occasions

after the
initial
screening
was equal
to or higher
than 140/90
mmHg
according to
JNC V1
classificatio
n.10
Hypertensiv
es whose
blood
pressure
was
<140/90
mmHg were
regarded as
having good
blood
pressure
control.
Those with
fair control
had blood
pressure of
140-179/90109 mmHg
while those
with poor
blood
pressure
control had
blood
pressure
180/110m
mHg.

80

Sudan Med J 2010:46(2)

Original Article Hypertensive

retinopathy CO Omolase

Patients
who are
known
hypertensiv
es with the
BP <140/90
were
regarded as
having good
control. One
hundred
consenting
respondents
were
selected by
simple
random
sampling
and
interviewed
with the aid
of the study
instrument
(questionnai
re) by the
authors.
Informed
consent was
obtained
from each
of the
respondents
.
Information
obtained
included
their biodata and
duration of
hypertensio
n.

Information
about their
control of
blood
pressure
was
obtained
from their
case notes.
All the
patients had
fundoscopy
carried out
by the
author
responsible
for
corresponde
nce using a
direct
ophthalmos
cope.

Those with
early lens
opacities
had dilated
fundoscopy.
The dilation
of the pupils
was effected
with
tropicamide
eye drop.
Hypertensiv
e
retinopathy
was
classified
based on the
classificatio
n of Keith et

(18)

al . Grade
1 consists of
mild
generalized
retinal
arteriolar
narrowing.
Grade 2
consist of
more severe
generalized
narrowing,
focal areas
of arteriolar
narrowing
and arteriovenous
(AV)
nicking.
Grade 3
consists of
grade1 and
grade 2
signs plus
the presence
of retinal
haemorrhag
es,
microaneur
ysm, hard
exudates
and cotton
wool spots.
Grade 4
sometimes
referred to
as
accelerated
(malignant)
hypertensiv
e
retinopathy
consists of
all signs in
the

preceding
three grades
plus optic
disc
swelling
and macular
oedema.
Data
obtained
with the aid
of the study
instrument
was collated
and
analyzed
with SPSS
12.1.0
statistical
software
package.
Cross
tabulation
was done as
well as Chisquare test.
Statistical
significance
was P <
0.05.

Results
There were
one hundred
respondents
aged
between 3480 years.
There were
40 males
and 60
females.
Eighty six
were

married
while 14
were
widowed.

Frequency
Percentage
Farming
16

Twenty nine
of the
respondents
each had
tertiary
education
and
secondary
education
respectively.
Nineteen
had no
education
and

16
Trading
38
38
Civil service
18
18
Teaching
3
3
Clergy

23 had
primary
education.
The
occupation
of the
respondents
as detailed
in Table 1
showed that
majority of
them (38%)
were
traders.

1
1
Pensioner
14
14
Artisan
4
4
Unemployed
6
6

Table 1:
Occupation of
the
respondents

Occupation

Total
100
100

Duration of
hypertensio
n: 58% of
the
respondents
had
hypertensio
n for less
than 5
years, 24%
had it for 510 years,
3% had it
for 10-15
years
and15% had
it for more
than 15
years.

Blood
pressure
control:10%
had poor
control,
35% had
fair control
and 55%
had good
control.
Prevalence
of
hypertensiv
e
retinopathy:
As shown in
Table 2,
11% of the
respondents
had
hypertensiv
e
retinopathy

of different
degrees of
severity, 4%
had grade 1
hypertensiv
e
retinopathy,
6% had
grade 3
hypertensiv
e
retinopathy
while 1%
had grade 4
hypertensiv
e
retinopathy.
The
remaining
83% had
normal
fundus.

Table 2:
Fudoscopic
findings

Fundus
findings
Frequency
Percentage
Normal fundus
16
16
Grade 1
hypertensive
38
38
retinopathy

Total
100
Grade 3
hypertensive
18
18
retinopathy

Grade 4
hypertensive
3
3
retinopathy

Glaucoma
1
1

100

Blood
pressure
control
versus
fundoscopy
findings: As
shown in
Table 3, the
blood
pressure
control
affected the
fundus
findings.
However,th
e difference
amongst the
different
groups was
not
statistically
significant.

81

Sudan Med J 2010:46(2)

Original Article Hypertensive

retinopathy CO Omolase

Table 3:
Fundus
findings
versusblood
pressure
control.
Fundus
findings
Blood pressure
control

Grade 3
hypertensive
5
1
-

Poor
Fair

6
retinopathy

Good

Total
Normal
19
13
51

Grade 4
hypertensive
1
-

83
Grade 1
hypertensive
1

retinopathy

4
retinopathy

Glaucoma
1
3
2

6
Total
27
18
55

100

Discussion

More than
half of our
respondents
had at least
secondary
education;
this is quite
commendabl
e and could
have
contributed
to their
utilization of
specialized
health care. It
is also
important to
note that the
age range of
our
respondents

accounted
for the
young,
middle-aged
and elderly
thus
reducing age
related bias.
Majority of
our
respondents
have had
hypertension
for less than
5 years. This
may also be
one of the
contributory
factors to the
relatively
low
incidence of
hypertensive
retinopathy
in this study.
Our finding
is also in
keeping with
that of a
similar study
by Karki in
Nepal in
which
67.54% of
their study
population
had
hypertension
for 1-5
(21)

years .
The fact that
more than
half of our
respondents
had good

blood
pressure
control is
encouraging
and it is
likely to be
due to the
effective
management
of the
hypertensive
patients by
the medical
team in the
hospital
where this
study was
conducted. It
is the authors
considered
opinion that
the effective
health
education
which was
carried out
on all clinic
days is likely
to have
increased
patients
compliance
with
treatment
thus
contributing
to
achievement
of optimal
blood
pressure
control in the
respondents.
One is also
not surprised

at this
finding in
view of the
fact that
patients are
able to
readily
procure
antihyperten
sive drugs at
affordable
prices at the
hospitals
pharmacy
which runs a
drug
revolving
scheme.
This
relatively
good blood
pressure
control is
also higher
than that of
a Nepal
study in
which
72.18% of
the

respondents
had poor
blood
pressure
(21)

control . A
blood
pressure
control rate
of 46% was
also reported
by Hussain
et al in

(22)

Sudan .
Development
of new
hypertensive
retinopathy
signs are
strongly
related to
elevated
blood
pressure. The
control of
hypertension
is important
to prevent
visual loss as
well as
reducing
morbidity
and mortality
arising from
hypertension.

Hypertensive
retinopathy is
a recognized
cardiovascula
r risk
stratification
factor. In
fact, an
assessment
of
hypertensive
retinopathy
signs for risk
stratification
is supported
by
International
hypertension
management
guidelines
including the

US joint
national
committee
on
prevention
detection,
evaluation
and
treatment of
high blood
pressure(JN
C) and
British
Society of
hypertension
(23,24)

The low
prevalence
of
hypertensive
retinopathy
in this study
is not
surprising in
view of the
relatively
good blood
pressure
control of
our
respondents.
It is lower
than the
prevalence
of 58.93%
reported by
Karki in
(21)

Nepal .
The
relatively
high
prevalence

of
hypertensive
retinopathy
in Karkis
study is
likely to be
related to the
poor control
of blood
pressure in
their study
population.
Keith,
Wagener and
Barker
classification
was used in
this study
being the
most widely
accepted and
easy to
follow.
However,
ophthalmosc
opically it is
most of the
time difficult
to
differentiate
between
grade 1 and
grade 2
hypertensive
retinopathy.
The other
problem is
that some of
the fundus
changes in
hypertension
do not fit into
any of the
grades. We

utilized
direct
ophthalmosc
ope for
fundoscopy
in this study.
It is a cheap,
readily
available
non invasive
and handy
instrument
by which the
changes in
the retinal
vasculature
and optic
nerve can be
visualized
directly in
vivo. This is
the reason
why at times
the
Ophthalmol
ogist is the
first
physician to
diagnose
asymptomati
c
hypertensive
patients. The
fundus
changes may
be a
reflection of
changes that
are going on
in other
organs of the
body like the
heart,

82

Sudan Med J 2010:46(2)

Original Article Hypertensive

retinopathy CO Omolase

brain and
kidney.
Thus, it is
important
for
physicians
and
ophthalmol
ogists to
pursue a
joint and
coordinated
approach to
prevent loss
of vision
from
complicatio
ns arising
from
hypertensio
n.

In
conclusion,
few
respondents
had
hypertensiv
e
retinopathy
of varying
degrees
with grade 3
accounting
for more
than half of
them. The
majority of
the
respondents

had good
blood
pressure
control and
this
accounted
for the low
prevalence
of
retinopathy.

There is a
need to
educate
hypertensiv
e patients
about the
need to
comply
with
treatment
and have
regular
ocular
examination
by an
ophthalmol
ogist.
Physicians
should
ensure
optimal
control of
blood
pressure to
prevent
complicatio
ns and end
organ
damage.

Acknowled
gment

Special
thanks to the
respondents
for
graciously
accepting to
participate

References
:

Hayreh SS.
Systemic
arterial
blood
pressure and
the eye. Eye
1996;10:528.

Akpa MR,
Agomuoh
DI and Odia
OJ. Drug
compliance
among
hypertensive
patients in
Port
Harcourt,
Nigeria. Nig
J Med
2005;114(1)
:55-7.
Chobanian
AV. Control
of
Hypertensio
n an

on this
study. We
also
acknowledg
e and value
the support
of the
Federal
Medical
Centre,
Owo, Ondo
State.
important
National
Priority
(Editorial)
N Engl J
Med
2001;345:5
34-5.

WolfMaierk,
Cooper RS,
Banegas
JR, et al.
Hypertensio
n
prevalence
and blood
pressure
level in 6
European
Countries,
Canada and
the United
States.
JAMA
2003:289(1
8): 2363-9.

Gorelick
PB. New
Horizons
for Stroke

Prevention.
PROGRESS
and HOPE.
Lancet
Neurology
2002;1:14956.
Grosso A,
Veglio F,
Porta M,
Grignolo
FM, Wong
TY.
Hypertensio
n
retinopathy
revisited:
some
answers
more
questions.
Br J
Ophthalmol
2005;89
1646-54.

Akinkugbe
OO(ed).
Final report
of national
survey of
noncommunicab
le diseases
in Nigeria
Ed, Lagos:
Federal
Ministry of
Health and
Social
Services;
1995.

Wolffohn
JS,
Hurcomb

PG.
Hypertensio
n and the
eye. Curr
Hypertens
Rep
2002;4(6):4
71-6.
ChatterJee
S,
Chattopadh
ya S, HopeRoss M,
Lip PL.
Hypertensiv
e and the
Eye:
changing
perspective.
J Hum
Hypertens
2002;16(10
):667-75.

Joint
National
Committee
on
Prevention
Detection,
Evaluation
and
Treatment
of High
Blood
Pressure.
The sixth
report of
the Joint
national
committee
on
prevention,

detection,
evaluation

and
treatment of
high blood
pressure
(JNCVI)
Arch Intern
Med
1997;167:24
13-46.

Klein R.
Retinopathy
in a
Population
based study.
Trans Am
Ophth Soc
1992;90:561
-694.
Klein R,
Klein B,
Moss S.
Blood
pressure
hypertension
and
retinopathy
in a

population.
Trans Am
Ophth Soc
1993;91:207
-22.
Klein R,
Klein B,
Moss S,
Wang Q.
Hypertensio
n and
retinopathy,
anteriolar

narrowing
and
anterioveno
us nicking
in a
population.
Arch
Ophthalmol
1994;112:9
2-

Yu T,
Mitchell P,
Berry G, Li
W, Wang JJ.
Retinopathy
in older
persons
without
diabetes
and its
relationship
to
hypertensio
n. Arch
Ophthalmol
1998;116:8
3-9.

UK
Prospective
Diabetes
Study
Group.
Tight blood
pressure
control and
rsk of
macrovascu
lar and
microvascul
ar
complicatio
ns in type 2
diabetes:
UKPDS

BMJ
1998;317:70
3-13.
UK
Prospective
Diabetes
Study
Group.
Efficacy of
atenol and
captopril in
reducing
risk of
microvascul
ar and
microvascul
ar
complicatio
ns in type of
diabetes
UKPDS
BMJ 1998;
317:713-9.
Sjolie Ak,
Stephenson

83

Sudan Med J 2010:46(2)

J, Aldington
S, et al.
Retinopathy
and vision
loss in
insulin
dependent
diabetes in
Europe. The
EURODIA
B IDDM
Complicati
ons Study
Ophthalmol
ogy
1997;104:
252-60.

Keith N,
Wagener
HP, Banker
N. Some
different
types of
essential
hypertensio
n.

Original Article Hypertensive

retinopathy CO Omolase

Their course
and
prognosis.
AMJ Med
Sci
1939;197:33
2.

Hayrey SS.
Classificatio
n of
hypertensiv
e fundus
changes and
their order
of
appearance.
Ophthalmol
ogical
1989;198:24
7-60.

Patel V,
Kohner EM.
Eye in
hypertensio
n In: Swales
JD (ed)
Textbook of
hypertensio
n. Oxford.
Blackwell
Scientific
Publications
1994:101525.

Karki KJD.
Incidence of
ophthalmos
copic

fundus
changes in
hypertensiv
e patients.
Kathmandu
University
Medical
Journal
2003:1(1):2
7-31.

Hussain
AA,
Elzubier
AG, ElBagir AM.
Target organ
involvement
in
hypertensiv
e patients in
Eastern
Sudan. J
Hypertens
1989;13:912.

Williams B,
Pottler NR,
Brown MJ,
et al. British
hypertensio
n society
guidelines
for
hypertensio
n
managemen
t
2004(BHS1V) :
summary.
BMJ

2004;328:63
4-40.
Chobanian
AV, Barkris
GL, Black
HR, et al.
The seventh
report of the
joint
national
committee
on

prevention,
detection,
evaluation
and
treatment of
high blood
pressure:
JCN 7
Report.
JAMA
2003;289(1
9):2560-72.

84

Sudan Med J 2010:46(2)