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RETINOPATHY
DEFINITION
the ophthalmic findings of end-organ damage secondary to
systemic arterial hypertension(defined as systolic greater
than 140 mmHg and diastolic greater than 90 mmHg)
Including optic neuropathy, choroidopathy, and
retinopathy
2 form :
- Chronic Hypertensive Retinopathy
- Malignant Acute Hypertensive
Retinopathy
EPIDEMIOLOGY
Second most common retinal vascular disease
incidence confounded by other retinal vascular
diseases, such as diabetes
Prevalence of Hypertension in Thailand = 22% in
men and 21.4% in women
Incidence of hypertensive retinopathy was about
15%(Beaver Dam Eye Study)
Systemic Hypertension 10-15% in UK(> 40 aged
group)
Malignant Hypertension(200/140mmHg) 1% of
Hypertension
SEVERITY
arteriosclerotic hypertensive retinopathy is the
duration of elevated blood pressure
malignant hypertension is the amount of blood
pressure elevation over normal
GENERAL PATHOLOGY
In ocular arterioles:
elevated luminal BP
vasoconstriction (to reduce flow) endothelial
damage smooth muscle degeneration
stretching, break, and leakage of plasma into
wall mural thickening + luminal narrowing
fibrinous necrosis
4 stages of Keith Wagener Barker (KWB)
Grades
PATHOPHYSIOLOGY
As a result of fibrinous necrosis
necrotic vessels bleed into nerve fiber layer
(flame shaped hemorrhage)
necrotic vessels bleed into inner retina (dot blot
hemorrhage)
Ischemia to the nerve fibers decreased
axoplasmic flow nerve swelling fluffy
opacification (cotton wool spots)
lipid accumulation surrounding areas of
hemorrhage (exudates)
PATHOPHYSIOLOGY
Grade
Grade
Grade
Generalised
As
As
As
CRITERIA DIAGNOSIS
Made by thorough history of the patient,
ophthalmoscopy (direct or indirect) and also
physical examination
History
Decrease
of patient vision
Occipital headache
High blood pressure
Possible history of systemic hypertension
CRITERIA DIAGNOSIS
Physical examination
Opthalmoscopy
CRITERIA DIAGNOSIS
Early malignant
Advanced
malignant
CRITERIA DIAGNOSIS
Sphygmomanometry
Arteriole
narrowing
Young patients :
autoregulation causes
uniform narrowing of
retinal arterioles
Older patients :
arterosclerosis and
autoregulation causes
focal narrowing of retinal
arterioles
CLASSIFICATION
Keith-Wagener-Barker classification
Grad
e
Description
Grade 1
Grade 2
Grade 3
Grade 4
CLASSIFICATION
Scheie classification
Staging under this system is as follows:
Stage 0 - Diagnosis of hypertension but no visible retinal abnormalities
Stage 1 - Diffuse arteriolar narrowing; no focal constriction
Stage 2 - More pronounced arteriolar narrowing with focal constriction
Stage 3 - Focal and diffuse narrowing, with retinal hemorrhage
Stage
4 - Retinal
edema, hard
exudates,
The Scheie
classification
also
gradesoptic
the disc
lightedema
reflex changes from
arteriolosclerotic changes, as follows:
Grade 0 - Normal
Grade 1 - Broadening of light reflex with minimal arteriolovenous compression
Grade 2 - Light reflex changes and crossing changes more prominent
Grade 3 - Copper-wire appearance; more prominent arteriolovenous
compression
Grade 4 - Silver-wire appearance; severe arteriolovenous crossing changes
CLASSIFICATION
Modified Scheie classification
Grade 0 - No changes
Grade 1 - Barely detectable arterial narrowing
Grade 2 - Obvious arterial narrowing with focal irregularities
Grade 3 - Grade 2 plus retinal hemorrhages and/or exudates
Grade 4 - Grade 3 plus disc swelling
MANAGEMENT
Appropiate
- Non-urgent referral
HYPERTENSIVE RETINOPATHY
ASSOCIATED CONDITIONS
Retinal vein occlusion
Retinal arterial occlusion
Retinal arterial macroaneurysm
Anterior ischemic optic neuropathy
Ocular motor nerve palsy
Uncontrolled hypertension may adversely
affect diabetic retinopathy
CLINICAL PEARLS