HYPERTENSIVE RETINOPATHY

Arranged By:
Sylvia Ruth Alisa Nababan 1361050211
Patricia Yasintha Waruwu 1361050222
Benedick Johanes Alvian 1361050223
Maria Natasha Marlinang Simanjuntak 1361050245
Anadia Rahma Savitra 1361050272
Hillery Briliani Octarina 1361050275

Tutor:
Dr. dr. Gilbert W. S. Simanjuntak, Sp. M (K)
Definition
• Hypertensive retinopathy describes a spectrum of
retinal changes in patients with elevated blood
pressure (BP).

• Hypertensive retinopathy represents the ophthalmic

findings of end-organ damage secondary to
systemic arterial hypertension.
High blood pressure (BP) causes a series of
pathophysiological changes in the retinal vasculature,
including focal and diffuse narrowing of the retinal arteriole,
opacifica-tion of the arteriolar wall, and compression of the
venules by arterioles.
Epidemiology
In the United States, an estimated :
25% of all adults and 60% of individuals over 60 years are
hypertensive.
In the National Health and Nutrition Study (NHANES III) that
evaluated hypertensive adults aged 18–74 years:

• 68.4% were aware of their hypertension

• 53.6% were receiving treatment
• 27.4% had their hypertension under control.
Hypertensive Retinopathy Classification

Keith Wagner and

Barker (1939)
Scheie’s Classification
Keith Wagner and Barker (1939)
GRADES FUNDUS EXAMINATION CARDIORENAL FUNCTION
Grade 1 Mild to moderate narrowing or Normal
Mild hypertension sclerosis of the arterioles

Grade 2 • Moderate to marked arteriolar sclerosis Satisfactory

Moderate hypertension • Exaggeration of light reflex
• Typical arteriovenous crossing changes

Grade 3 • Marked retinal arteriolar narrowing Evidences of

Hight and sustained hypertension
Grade 4
Malignant hypertension
• Retinal oedema disease and focal constriction cardiorenal
• Cotton wool / (soft) exudates
• Superficial flame-shaped
haemorrhages
• Grade 3 plus Marked Cardiorenal damage
• Macular star
• Papilloedema
 Scheie’s Classification
A. Hypertensive features
Grade 0 - Normal fundus.

Grade 1 - Narrowing of smaller retinal arterioles. There is no

focal constriction.
Grade 2 - Severe narrowing with localized irregular constriction
of the arterioles.
Grade 3 - Narrowing and focal irregularities of arterioles, retinal
haemorrhage and exudates.

Grade 4 - All changes in grade 3 along with neuroretinal oedema,

and / or papilloedema.
B. Arteriolo-sclerotic features
Grade 0 - Normal fundus.

Grade 1 - Widening of arteriolar light - reflex with simple venous

concealment.
Grade 2 - Grade 1 changes with deflection of veins at the AV (Salus
sign).
Grade 3 - Grade 2 changes with ‘copper wire’ arterioles and marked AV
crossing changes.
• Banking of veins distal to arteriovenous crossings (Bonnet
sign).
• Tapering of veins on both sides of the AV crossings (Gunn
sign) and rightangled
deflection of veins.
Grade 4 - Grade 3 changes with ‘silver wire’ arterioles and marked AV
crossing changes.
Risk Factor

Stroke and cerebrovascular

Blood pressure Atherosclerosis risk factors
disease

Coronary heart disease and

Other systemic diseases
heart failure
PATHOPHYSIOLOGY
• acute blood pressure elevation causes reversible
vasoconstriction in retinal blood vessels and hypertensive crisis
may cause optic disc oedema (vasospastic response)
• Prolonged and severe hypertension leads to exudative vascular
changes due to endothelial damage and necrosis
• Chronic (years) elevation of blood pressure results in
atherosclerosis through medial hyperplasia and fibrosis,
manifests as arteriole wall thickening and arteriovenous nicking
(atherosclerotic response)
• Hypertension is a major risk factor for other retinal disorders (eg,
retinal artery or vein occlusion, diabetic retinopathy).
• hypertension combined with diabetes greatly increases risk of
vision loss.
• Patients with hypertensive retinopathy are at high risk of
hypertensive damage to other end organs
Symptoms and Signs
• Symptoms usually do not develop until late in the disease and
include blurred vision or visual field defects
• In the early stages, funduscopy identifies arteriolar constriction,
with a decrease in the ratio of the width of the retinal arterioles to
the retinal venules
• Chronic, poorly controlled hypertension causes the following:
• Permanent arterial narrowing
• Arteriovenous crossing abnormalities (arteriovenous nicking)
• Arteriosclerosis with moderate vascular wall changes (copper wiring) to
more severe vascular wall hyperplasia and thickening (silver wiring)
• If acute disease is severe, the following can develop:
• Superficial flame-shaped hemorrhages
• Small, white, superficial foci of retinal ischemia (cotton-wool spots)
• Yellow hard exudates
• Optic disk edema
• In severe hypertension, the optic disk becomes congested and
edematous (papilledema indicating hypertensive crisis).
DIAGNOSE OF
HIPERTENSIVE
RETINOPATHY
Diagnose
• Hypertensive retinopathy is diagnosed based upon its clinical
appearance on dilated fundoscopic exam and coexistent
hypertension.
History
• To gauge hypertension disease severity, patients should be
asked about their severity and duration of hypertension, and
about the medications taken as well as compliance. Symptoms
of hypertension to ask about include headaches, eye pain,
reduced visual acuity, focal neurological deficits, chest pain,
shortness of breath, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, and palpitations. Patients should be asked
about the complications of hypertension, including history of
stroke or transient ischemic attack, history of coronary or
peripheral vascular disease, and history of heart failure.
Physical examination
The physical exam on patient with hypertension includes:
• Vital signs
• Cardiovaskular exam
• Pulmonary exam
• Neurological exam
• Dilated funduscopy
Signs
• The signs of malignant hypertensive retinopathy include
constricted and tortuous arterioles, retinal hemorrhage, hard
exudates, cotton wool spots, retinal edema, and papilledema.
• the signs of chronic arterial hypertension in the retina include
widening of the arteriole reflex, arteriovenous crossing signs,
and copper or silver wire arterioles (copper or silver colored
arteriole light reflex). Hypertension causes choroidopathy.
Early malignant Advanced
malignant
Focal narrowing of retinal arterioles-Copper and Silver wiring
Symptoms
Acute malignant hypertension will cause patient to complain of
• Eye pain
• Headaches
• Or reduced visual acuity
Chronic arteriosclerotic changes from hypertension will not
cause any symptoms alone
Clinical diagnosis
The signs of malignant hypertension are well summarized by the
Modified Scheie Classification of Hypertensive Retinopathy

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, exudates, cotton
wool spots, or retinal edema
Grade 4: Grade 3 plus papilledema
Diagnostic procedures
• Fluorescein angiography (FA) during acute malignant
hypertension will demonstrate retinal capillary nonperfusion,
microaneursym formation, and a dendritic pattern of choroidal
filling in the early phase. In the late phase, diffuse leakage will
be seen[. Indocyanine green angiography during malignant
hypertension will show a moth eaten appearance of the
choriocapillaris. Fluorescein angiography can demonstrate
hypertensive choroidopathy. FA will show focal choroidal
hypoperfusion in the early phases and subretinal leakage in the
later phases.
Laboratory test
• Laboratory tests are not routinely helpful for the diagnosis of
hypertension. Laboratory tests can be useful for risk stratification
and monitoring of complications.
• These tests include echocardiography, electrocardiography,
serum electrolytes, serum creatinine, urinalysis, fasting lipid
profile, serum glucose, and hemoglobin A1C.
Differential Diagnosis
• The differential for hypertensive retinopathy with diffuse retinal
hemorrhage, cotton wool spots, and hard exudates includes
most notably diabetic retinopathy. Diabetic retinopathy can be
distinguished from hypertensive retinopathy by evaluation for the
individual systemic diseases. Other conditions with diffuse
retinal hemorrhage that can resemble hypertensive retinopathy
include radiation retinopathy, anemia and other blood
dyscrasias, ocular ischemic syndrome, and retinal vein
occlusion.
TREATMENT HYPERTENSIVE
RETINOPATHY
Risk Stratification and Management Guidelines of Hypertensive Retinopathy
Retinopathy Grade Description Systemic Associations Management
Mild One or more of the
following signs:
Weak associations with
Generalized arteriolar
stroke, coronary heart •Routine care
narrowing, focal arteriolar
disease and •Closer monitoring of
narrowing, arteriovenous
cardiovascular mortality vascular risk
nicking, arteriolar wall
opacity (silver-wiring)
Moderate
Mild retinopathy with one
Strong association with •Exclude diabetes
or more of the following
stroke, congestive heart •Closer monitoring of
signs: Retinal hemorrhage
failure, renal dysfunction, vascular risk
(blot, dot or flame-shaped),
and cardiovascular •Possible indication for
microaneurysms, cotton
mortality hypertension treatment
wool spot, hard exudates
and other risk factor
Malignant Moderate retinopathy signs
plus optic disc swelling and Associated with mortality •Urgent hypertension
macular edema treatment
Treatment Hypertensive Retinopathy
1. Normalizing the blood pressure in a controlled manner
(reduce the systemic blood pressure below 140/90 mmHg).
The retina will often recover if blood pressure is controlled.
2. Successful treatment of the underlying cause
3. Improvement in the ocular changes
Treatment Hypertensive Retinopathy
• Anti hypertensive drugs are started, such as amlodipine and
angiotensin-converting enzyme (ACE) inhibitors.
• If the retinas are detached, oral steroids may be considered,
because topical medications applied to the eye do not reach the
retina.
• Oral steroids must be used with caution, however, because they
may aggravate uncontrolled hypertension and are
contraindicated with some of the underlying diseases that cause
hypertension.
Treatment Hypertensive Retinopathy
1. A diet high in fruits and vegetables may help lower blood
pressure.
2. Regular physical activity, reducing salt intake, reducing
cholesterol levels, and limiting the amount of caffeine and
alcoholic will contribute to healthy blood pressure as well.
3. Stop smoking.
4. Losing weight for overweight is an effective strategy for
controlling high blood pressure.
Follow-up Care Eye
Follow-up Care Eye and physical examinations and blood
pressure measurements are commonly repeated every 7-14
days until blood pressures are normal and the ocular signs
improve.
The frequency of follow-up visits depends on how well the
ocular changes respond to therapy and what is required to treat
the underlying disease.
Prognosis
• If the hypertension can be controlled, most ocular abnormalities
improve and slowly resolve.
• It may take several weeks to months for hyphema to dissipate
and retinal hemorrhages to fade.
• Abnormalities of the pupil may persist after hyphema, and retinal
scarring is com- mon in areas where hemorrhages occurred.
• If retinal detachments are diagnosed early and the hypertension
is treated aggressively, reattachment of the retina can occur
• Wong TY, Mitchell P Hypertensive retinopathy. N Engl J Med
2004;351:2310–17.
• Ruilope LM, Schiffrin EL. Blood pressure control and benefits of
antihypertensive therapy: does it make a difference which
agents we use? Hypertension 2001;38:537–42.
COMPLICATION &
PROGNOSIS
Complication
• Rarely results in significant vision loss
• Vision loss may occurs  from retinal pigment changes,
secondary to retinal detachment or from optic atrophy due to
prolonged papilledema
Prognosis
• If untreated  mortality rate 50% at 2 months, 90% at 1 year.
• Most patients will resume normal vision.
Conclusion
• Hypertensive retinopathy  spectrum of retinal changes in
patients with elevated blood pressure
• Most patients remain undiagnosed or inadequately treated
despite the relative ease of detection
• If the hypertension can be controlled, most ocular abnormalities
improve and slowly resolve
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