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Ocular System

Hypertensive retinopathy

Retinal vascular damage caused by hypertension.

Retinal vascular damage caused by hypertension.


Pathophysiology

Poorly controlled hypertension (HTN) affects several systems resulting in target-organ damage (TOD)

  • HTN affects the eye causing 3 types of ocular damage:
    • Choroidopathy
    • Retinopathy
    • Optic neuropathy

Arteriolar changes:

  • Generalized arteriolar narrowing
  • Focal arteriolar narrowing
  • Arteriovenous nicking
  • Arteriolar wall opacification

Advanced retinopathy lesions:

  • Microaneurysms
  • Blot and flame-shaped haemorrhages
  • Cotton-wool spots
  • Hard exudates
  • Optic disk swelling

Clinical features

Keith-Wagener-Barker classification (1939):

Useful in prognosticating for survival
  • Grade 1: Mild generalized retinal arteriolar narrowing
  • Grade 2: Definite focal narrowing and arteriovenous nipping
  • Grade 3: Grade 2 + retinal hemorrhages, exudates and cotton wool spots
  • Grade 4: Severe grade 3 + ‘silver wiring’ papilledema

Wong and Mitchell classification (2004):

Easier to use
  • Mild: ≥ 1 of the following signs: generalized arteriolar narrowing, focal arteriolar narrowing, arteriovenous nicking, arteriolar wall opacity
  • Moderate: ≥ 1 of the following signs: retinal hemorrhage (blot-, dot-, or flame-shaped), microaneurysm, cotton wool spot, hard exudates
  • Severe: Moderate retinopathy + optic disc swelling
Grades of hypertensive retinopathy. (A) Mild hypertensive retinopathy (in an eye with an unrelated chorioretinal lesion) with arteriolar narrowing (white arrow), copper wiring (black star), and AV nicking (black arrow). (B) Moderate hypertensive retinopathy with features of mild hypertensive retinopathy as well as cotton wool spots (yellow arrow) and intraretinal hemorrhages (red arrow). (C) Severe hypertensive retinopathy with features of moderate hypertensive retinopathy and optic disc swelling (white star). | Tsukikawa, M., & Stacey, A. W. (2020). A Review of Hypertensive Retinopathy and Chorioretinopathy. Clinical optometry, 12, 67–73. https://doi.org/10.2147/OPTO.S183492

Diagnosis

Funduscopic exam:

  • Copper wiring
  • AV nicking
  • Cotton-wool spots
  • Intraretinal hemorrhages
  • Elschnig spots
  • Optic disc swelling
Optos wide-field color fundus photographs of the right eye (A) and left eye (B) of a patient with hypertensive chorioretinopathy. The photographs demonstrate copper wiring (black star), AV nicking (black arrow), intraretinal hemorrhages (red arrow), cotton wool spots (yellow arrow), Elschnig spots (white asterisk), and optic disc swelling (white star). | Tsukikawa, M., & Stacey, A. W. (2020). A Review of Hypertensive Retinopathy and Chorioretinopathy. Clinical optometry, 12, 67–73. https://doi.org/10.2147/OPTO.S183492

Optical coherence tomography (OCT):

  • Thinning of the inner retina
  • Focal attenuation of the ellipsoid zone in areas of the Elschnig spots
  • Pigmentary epithelial detachments
  • Serous retinal detachments
Optical coherence tomography of the macula of the right eye (A) and left eye (B) of a patient with hypertensive chorioretinopathy shows macular edema and serous retinal detachments. These serous retinal detachments improved after medical management of hypertension. | Tsukikawa, M., & Stacey, A. W. (2020). A Review of Hypertensive Retinopathy and Chorioretinopathy. Clinical optometry, 12, 67–73. https://doi.org/10.2147/OPTO.S183492

Fundus autofluorescence:

  • Hypoautofluorescence of Elschnig spots
  • Hypoautofluorescence due to intraretinal hemorrhages and cotton wool spots
Fundus autofluorescence of the right eye (A) and left eye (B) of a patient with hypertensive chorioretinopathy. Magnification of the posterior pole reveals hypoautofluorescence of Elschnig spots, retinal hemorrhages and cotton wool spots. | Tsukikawa, M., & Stacey, A. W. (2020). A Review of Hypertensive Retinopathy and Chorioretinopathy. Clinical optometry, 12, 67–73. https://doi.org/10.2147/OPTO.S183492

Fluorescein angiography:

  • Patchy and delayed choroidal filling
  • Severely delayed retinal arterial filling with areas of retinal capillary nonperfusion
  • Elschnig spots appear as areas of early hyperfluorescence with late subretinal leakage
  • Optic disc leakage and blockage from cotton wool spots and intraretinal hemorrhages
  • Indocyanine green (ICG) angiography: Demonstrates hypocyanescence of ischemic areas of the choroid.10
Fluorescein angiography of the right eye (A) and left eye (B) of a patient with hypertensive chorioretinopathy shows patchy and delayed choroidal filling and areas of retinal capillary nonperfusion. There is also blockage from intraretinal hemorrhages and cotton wool spots, as well as optic disc leakage. | Tsukikawa, M., & Stacey, A. W. (2020). A Review of Hypertensive Retinopathy and Chorioretinopathy. Clinical optometry, 12, 67–73. https://doi.org/10.2147/OPTO.S183492

Differential diagnosis:

  • Diabetic retinopathy
  • Radiation retinopathy
  • Anaemia and other blood dyscrasias
  • Ocular ischemic syndrome
  • Retinal vein occlusion

Management

Control of hypertension

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