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Hypertensive Retinopathy

Hypertensive retinopathy, formerly termed as "albuminuric retinitis", is a condition characterized by appearance of a series of changes in the retinal vasculature occurring as a result of acutely severe or prolonged, consistent systemic hypertension.


Presentation

The signs and symptoms of hypertensive retinopathy usually develop in later stages of the disease. Most patients are asymptomatic although some may present with headaches, blurred vision or loss of vision. In emergency situations, symptoms of stroke may start to appear which requires immediate hospitalisation and prompt management. 

The fundoscopic examination of patients in earlier stages of the disease reveals constriction of arterioles. Findings that present with chronic, prolonged hypertension include arteriovenous nicking and vascular wall changes that are identified by copper wiring and silver wiring. 

In acute, severe cases of hypertensive retinopathy characteristic flame-shaped hemorrhages, cotton wool spots, yellow hard exudates and optic disk edema are identified during examination. Generalized signs of extravascular lesions that accompany hypertensive retinopathy include microaneurysms, retinal hemorrhages, edema of retina and macula, lipid deposition on retina and focal intraretinal periarteriolar transudates (FIPTs).

Abdominal Obesity
  • , an indicator of abdominal obesity. 25 However, not all studies have found associations between hypertensive retinopathy signs and abdominal obesity or dyslipidaemia. 18 The association of hypertensive retinopathy signs with novel atherosclerosis risk[doi.org]
Short Stature
  • BACKGROUND: A 60 member Turkish kindred with autosomal dominant hypertension, which cosegregates completely with brachydactyly and short stature, was studied. Affected people have severe hypertension and generally die of stroke by the age of 50.[ncbi.nlm.nih.gov]
Recurrent Urinary Tract Infection
  • The major clinical conditions are recurrent urinary tract infection (UTI) and voiding dysfunction. This report describes a 15-year-old male adolescent who developed sudden visual disturbance resulting from hypertensive retinopathy.[ncbi.nlm.nih.gov]
Sneezing
  • We do not endorse non-Cleveland Clinic products or services Policy A 19-year-old male college student presented to the ER with a four-day history of left eye pain and redness that began after a sneeze.[consultqd.clevelandclinic.org]
Retinal Hemorrhage
  • Increased vascular permeability and leakage follows which ultimately results in small retinal hemorrhages, hard exudates and retinal edema. Papilledema is another finding that is specific to accelerated hypertension.[symptoma.com]
  • Arteriovenous crossing changes and capillary bed abnormalities, such as cotton-wool spots, retinal hemorrhages, and retinal edema were also mentioned, as well as blurred discs.[ncbi.nlm.nih.gov]
  • Retinal photographs were taken of one randomly selected eye and evaluated for the presence of retinopathy (flame and blot-shaped retinal hemorrhages, microaneurysms, and soft exudates) according to standardized protocols by graders masked to participant[ncbi.nlm.nih.gov]
  • Seven (18%) of the 39 children receiving ophthalmic assessment had hypertensive retinopathy, of whom 6 had severe disease (retinal hemorrhages, exudates, and optic disc edema).[ncbi.nlm.nih.gov]
  • […] with focal irregularities Grade 3 – Grade 2 plus retinal hemorrhages and/or exudates Grade 4 – Grade 3 plus disc swelling Classification of hypertensive retinopathy by Wong and Mitchell Grades Description Systemic associations No retinopathy No detectable[rpcround.wordpress.com]
Flame-shaped Hemorrhage
  • Ophthalmoscopy showed bilateral optic disc edema, soft exudates, macular star, flame-shaped hemorrhages and arterial narrowing. The situation was more severe in the right eye.[ncbi.nlm.nih.gov]
  • Funduscopic examination shows arteriolar constriction, arteriovenous nicking, vascular wall changes, flame-shaped hemorrhages, cotton-wool spots, yellow hard exudates, and optic disk edema.[msdmanuals.com]
  • Chronic HTN : Arteriovenous crossing changes (“AV nicking”), retinal arteriolar sclerosis (“copper” or “silver” wiring), cotton-wool spots, flame-shaped hemorrhages, arterial macroaneurysms, central or branch occlusion of an artery or vein.[medium.com]
  • Findings in hypertensive retinopathy include cotton wool spots and flame shaped hemorrhages. Only rarely will there be retinal or macular edema.[web.archive.org]
Retinal Lesion
  • lesions are associated with unfavourable cardiovascular prognosis independently of confounders and traditional risk factors [2–5].[journals.lww.com]
  • lesions are associated with unfavourable cardiovascular prognosis independently of confounders and traditional risk factors [2–5] .[journals.lww.com]
  • Cotton-wool spots typically resolve in 3–6 weeks and are associated with permanent nerve fiber layer loss in the vicinity of the lesion.[12] Periarteriolar intraretinal transudates are tan-white retinal lesions occurring in the vicinity of an arteriole[medtextfree.wordpress.com]
  • A correlation between retinal lesions, as detected by direct ophthalmoscopy, and left ventricular hypertrophy, as defined by echocardiography, was suggested 64 but the study was limited by the imprecision of clinical ophthalmoscopy in quantifying retinal[bjo.bmj.com]
  • Consisting of small, white, focal, oval lesions deep in the retina, they are associated with major arteriole vessels and are among the earliest retinal lesions caused by malignant hypertension.[emedicine.medscape.com]
Background Retinopathy
  • retinopathy and retinal vascular changes 2016 2017 2018 2019 Non-Billable/Non-Specific Code Code Also any associated hypertension ( I10.- ) Background retinopathy and retinal vascular changes Approximate Synonyms Bilateral hypertensive retinopathy Hypertensive[icd10data.com]
Suggestibility
  • Numerous experimental and clinical reports suggest that a high von Willebrand factor (vWF) level reflects endothelial damage or dysfunction.[ncbi.nlm.nih.gov]
  • A young female suffering from chronic kidney disease presented with retinal features suggestive of retinitis pigmentosa (RP). Cystoid intraretinal changes were noted at the macula in both eyes on optical coherence tomography.[ncbi.nlm.nih.gov]
  • Our study suggests that oxidative stress, mechanisms known to be involved in vascular lesions, may promote the development of HR.[ncbi.nlm.nih.gov]
  • The results suggest that intravitreal bevacizumab injections might be a useful adjunctive treatment of malignant hypertensive retinopathy in some selected cases.[ncbi.nlm.nih.gov]
  • Our study suggests that there is a relationship between HR and hs-CRP levels, which may be associated with systemic low- grade inflammation.[ncbi.nlm.nih.gov]
Papilledema
  • In second module, proposed system performs analysis of ONH region for possible signs of papilledema. This stage utilizes different features along with SVM and RBF for classification of papilledema.[ncbi.nlm.nih.gov]
  • It must be reiterated, however, that there are many causes of papilledema. Other causes of papilledema, such as an intracranial mass lesion, must also be considered in the patient with hypertension.[web.archive.org]
  • Ocular findings are severe and include exudative edema and papilledema. Very poor prognosis. The choroidal vasculature is also highly susceptible to hypertensive damage.[web.archive.org]
  • Introduction Focal spasms followed by progressive sclerosis and narrowing of retinal vessels Results in flame hemorrhage from vessel rupture, formation of exudates, and papilledema Presentation Symptoms vision loss Physical exam tortuous retinal veins[medbullets.com]

Workup

Diagnosis of hypertensive retinopathy is based on patient's history, retinal examination and fundoscopy. Routine opthalamoscopic examination is recommended in patients with stage III hypertension, in hypertensive patients presenting with visual symptoms and in general case of sustained hypertension. Alternatively, retinal changes can also be assessed through advanced digital photography of retinal structure using specialized software. Other diagnostic tools that have been used are the Keith and Scheie staging scales, although they do not indicate considerable changes in retinal structures of hypertensive patients. 

Ventricular Hypertrophy
  • Multivariate analysis showed that only septal and lateral S values were independent factors for the retinopathy and left ventricular hypertrophy, respectively.[ncbi.nlm.nih.gov]
  • The grade of hypertensive retinopathy was related to age, duration of hypertension, coronary artery disease (CAD), and left ventricular hypertrophy (LVH).[ncbi.nlm.nih.gov]
  • Hypertensive cardiovascular, renal and cerebrovascular changes were indicated by left ventricular hypertrophy (LVH), chronic kidney disease (CKD) and stroke, respectively.[ncbi.nlm.nih.gov]
  • After controlling for 6-year mean arterial blood pressure, use of antihypertensive medications and left ventricular hypertrophy by ECG criteria, the excess prevalence of retinopathy in African Americans was reduced by 40% (adjusted OR 1.61, 95% CI 1.26[ncbi.nlm.nih.gov]
  • Renal dysfunction, ECG abnormalities (ventricular hypertrophy, pathological Q wave, repolarization abnormalities), and history of stroke were observed in 70.0%, 27.0% and 10.0% of patients, respectively.[ncbi.nlm.nih.gov]

Treatment

Hypertension is the primary cause for the development of hypertensive retinopathy. Therefore, controlling hypertension is the first step in the management of the disease. It is imperative to keep blood pressure within normal range by keeping regular checks, getting periodic evaluation by a physician, dietary and lifestyle modifications and pharmacotherapy with prescribed antihypertensives. Mild damage to the retina resulting from acute hypertensive episode can be reversed. Complications like loss of vision require treatment with laser or administration of corticosteroids and antivascular endothelial growth factor drugs by the intravitreal route. Monoclonal antibodies ranibizumab and bevacizumab and pegaptanib are the recommended antivascular endothelial growth factors.

All hypertensive patients who are at risk of developing optic neuropathy or are already suffering from optic neuropathy must avoid sudden decline in blood pressure. The persistently elevated blood pressure in the vessels supplying optic nerve are autoregulated by adjusting blood supply according to higher blood pressure. Therefore, sudden decline in blood pressure cuts off the blood supply to the optic nerve causing nerve tissues to die. 

Surgical management is indicated to address certain secondary causes of systemic hypertension.

Prognosis

Timely diagnosis of hypertensive retinopathy is the key to limit worsening of retinal damage and avoid structural changes to optic nerve and macula. Once the retinal blood vessels undergo arteriosclerosis, further risks for developing retinal artery and vein occlusions and retinal microaneurysms become inevitable which in turn may precipitate peripheral vascular disease, coronary artery disease and stroke in the long run. Therefore, earlier diagnosis and management provides positive outcome with good prognosis.  

Etiology

Elevated blood pressure has been considered the leading cause in the development of retinal hypertension. Combined with diabetes mellitus, hypertension greatly raises the risk of vision loss. The risk of damage to other organs is increased in patients with hypertensive retinopathy. Smoking, although not a risk factor for hypertensive retinopathy, is thought to worsen the condition.

In a report published by the Beaver Dam Eye Study, it has been indicated that chronic hypertension is responsible for causing vascular changes in the retina, resulting in narrowing of arterioles and venules [6]. In a Beijing Eye Study, it was observed that generalized arteriolar narrowing and focal arteriolar narrowing occurs in 25.4% and 12.1% of patients with hypertension respectively [7]. Incidence of increased blood pressure in childhood can precipitate hypertension in young people during adulthood, leading to retinal hypertension. 

Epidemiology

Epidemiological studies have indicated that 3%-14% of non-diabetic individuals above 40 years of age suffer from hypertensive retinopathy, 12% of which develop focal narrowing of arterioles while 3%-17% have retinal hemorrhages [8] although non-hypertensive patients may also present with pathological modifications in retinal vasculature after 40 years. 

Sex distribution
Age distribution

Pathophysiology

A spectrum of focal and generalized signs occur in hypertensive retinopathy owing to autoregulatory physiological response by retinal vasculature due to elevated blood pressure (in acute phases). As hypertensive retinopathy progresses, the autoregulation mechanism becomes disrupted as the consistent rise in blood pressure causes structural and functional changes in the retinal arterioles (in chronic cases) [9] [10].

In acute phases, temporary vasoconstriction occurs  in the terminal retinal vasculature which causes narrowing of retinal arterioles as a result of physiological autoregulation. In chronic systemic hypertension, damage to vascular endothelium and cell necrosis cause visible and irreversible arteriosclerotic changes in the retinal vasculature. In severely prolonged hypertension that persists for years, other vascular changes further ensue which include localized signs of hypertensive retinopathy such as arteriolar wall thickening, arteriovenous nicking, microaneurysms, retinal hemorrhage and cotton wool spots and diffuse signs that comprise generalized arteriolar narrowing and arteriolar wall opacification [10].

Focal narrowing of retinal arterioles occurs due to vasospasm or edema of the retinal arterioles resulting from increase in intraluminal pressure whether in the retinal arterioles or in the central artery of the retina. Development of arteriosclerotic changes in chronic hypertension cause further sclerosis and hyalinization of retinal arterioles which causes them to become red-brown, a phenomenon known as copper wiring. When the hypertension continues for years, sheathing of vessels occurs by progression of arteriolar sclerosis to a more advanced stage. Sheathing of vessel wall is characterized by increase in optical density which further leads to pipe-stem sheathing in which the entire surface of vessel becomes opaque followed by vascular wall involvement, which ultimately produces a silver-wire vessel. Arteriovenous nicking occurring in prolonged hypertenion results from hindrance in blood circulation causing dilatation of retinal vein and hourglass constrictions, a phenomenon known as the Gunn sign. Cotton wool spots are small clogs present on the inner layer of retinal vessels where they appear as fluffy, white lesions. The spots are indication of small localized ischemic stroke of retinal blood vessels due to elevated blood pressure. Cotton wool spots typically appear in later stages of retinal hypertension with prolonged hypertension and last for about 3-6 weeks but reappear if hypertension persists, causing further damage [11].

Prevention

Controlling blood pressure is they key to prevent occurrence of hypertensive retinopathy later in life. Adopting a healthy lifestyle that includes incorporating healthy diet devoid of excess sugar and cholesterol, regular exercise, maintenance of healthy weight and getting regular examination from a physician help prevent end organ damage, including retinopathy. Following prescribed regimen of antihypertensive therapy is paramount in keeping sudden hypertensive episodes at bay. 

Summary

Hypertensive retinopathy, a state of target organ damage as indicated by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) [1] is referred to as damage to retinal vasculature as a result of systemic arterial hypertension. The series of ensuing retinal vascular changes develop on prolonged, severe and sustained hypertension [2] and are characterized by vascular exudations, arteriosclerosis (causing vascular narrowing), vascular leakage and retinal edema

Several international guidelines have categorized hypertensive retinopathy by providing grading systems. The European Society of Hypertension-European Society of Cardiology Guidelines (ESH-ESC 2003), the WHO International Society of Hypertension (WHO-ISH) 2003 and the British Hypertension Society 2004 Guidelines (BHS IV) have regarded that hypertensive retinopathy produces clinical signs in grades III and IV [3] [4] [5]. 

Hypertensive retinopathy produce focal and generalized signs on progression. Initially, arteriolar narrowing occurs followed by arteriosclerosis and disruption of the blood-retinal barrier in sustained, untreated hypertension. Increased vascular permeability and leakage follows which ultimately results in small retinal hemorrhages, hard exudates and retinal edema. Papilledema is another finding that is specific to accelerated hypertension.

Treatment and preventing progression of the disease is directed at controlling blood pressure. Hypertensive retinopathy is a preventable illness since end organ damage can be prevented by treating hypertension from the very start with antihypertensives and basic lifestyle modifications.

Patient Information

Hypertensive retinopathy is a condition secondary to high blood pressure in which the retina of the eye, a light sensitive transparent structure present behind the eye ball, is damaged. The blood vessels that supply blood to the retina are damaged during high blood pressure which causes hindrance in the flow of blood through those vessels and reduces blood supply to a large extent. With insufficient supply of blood, some areas of the retina become damaged and small patches or spots appear on the retina, indicating minor hemorrhages. If left uncontrolled, blood may end up leaking into the retina in later course of the disease and cause loss of vision over the years. 

In patients with diabetes, the risk for vision loss in hypertensive retinopathy increases by two fold. The condition is worsened by tobacco smoking. The disease has been found to occur in individuals above 40 years of age. 

Correct diagnosis at the right time is of utmost importance in order to achieve good outcome. Early diagnosis can help in staying away from complications by initial management. 

Hypertensive retinopathy is usually diagnosed by taking patient's history, retinal examination and fundoscopy. Hypertensive patients are advised to undergo routine opthalamoscopic examination even if minor signs of visual impairment appear. The opthalamoscope helps in observing physical appearance of the retina and detect minor changes in the eye structure during high blood pressure.

Signs and symptoms of the disease commonly appear later in the disease. Hypertensive retinopathy is characterized by headache, blurred vision or loss of vision

Treatment of hypertensive retinopathy is aimed at controlling blood pressure and keeping it on a lower side. Corticosteroid injections (Dexamethosone) and biological drugs (Ranibizumab, pegaptanib, aflibercept, bevacizumab) are commonly used medications. 

Hypertensive retinopathy is completely preventable if the patients keep their blood pressure within control from the beginning. Taking regular medications, adopting a healthy life style with exercise and healthy diet and regular checks ups can easily prevent the development of hypertensive retinopathy. 

References

Article

  1. Chobanian AV, Bakris GL, Black HR, et al. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.
  2. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004;351(22):2310-2317.
  3. European Society of Hypertension-European Society of Cardiology Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens. 2003;21(6):1011-1053. Erratum in: J Hypertens. 2003;21(11):2203-2204. J Hypertens. 2004;22(2):435.
  4. Whitworth JA. World Health Organization, International Society of Hypertension Writing Group. 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens. 2003;21(11):1983-1992.
  5. Wang S, Xu L, Jonas JB, et al. Major eye diseases and risk factors associated with systemic hypertension in an adult Chinese population: the Beijing Eye Study. Ophthalmology. 2009;116:2373-2380.
  6. Klein R, Myers CE, Knudtson MD, et al. Relationship of blood pressure and other factors to serial retinal arteriolar diameter measurements over time: the Beaver Dam Eye Study. Arch Ophthalmol. 2012;130:1019-1027.
  7. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004;351:2310-2317.
  8. Wang JJ, Rochtchina E, Kaushik S, et al. Long-term incidence of isolated retinopathy lesions in older persons without diabetes: the Blue Mountains Eye Study. Invest Opthalmol Vis Sci. 2010;51:ARVO E-Abstract 1236.
  9. Tso MO, Jampol LM. Pathophysiology of hypertensive retinopathy. Ophthalmology. 1982;89:1132-1145.
  10. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004;351:2310-2317.
  11. Albert D, Jakobiec F, Christlieb RA. Based on: Principles and Practice of Ophthalmology. In: Hypertension. WB Saunders Co;1993.

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Last updated: 2019-07-11 20:40