Hypertensive Retinopathy (2).pptx

opthalmology

1. HYPERTENSIVE RETINOPATHY

2. The arteriosclerotic changes in hypertensive retinopathy are caused by chronically elevated blood pressure (BP) Elevated blood pressure defined as SBP > 140 mmHg and DBP >90 mmHg. [1] Can be caused by either chronic primary or secondary hypertension (e.g. pheochromocytoma, primary hyperaldosteronism, Cushing’s syndrome, renal parenchymal disease, renal vascular disease, coarctation of the aorta, obstructive sleep apnea, hyperparathyroidism, and hyperthyroidism). [2] ETIOLOGY American Academy of Ophthalmology. Basic and Clinical Sciences Course (Lifelong Education for the Ophthalmologist). San Fransisco. 2006. Katakam, R., Brukamp, K., and Townsend, R.R. What is the proper workup of a patient with hypertension? Cleve Clin J Med . 2008;75:663-72.

3. EPIDEMIOLOGY Erden et al. showed that the incidence of hypertensive retinopathy directly proportional to the severity and duration of hypertension [1] A study in German population, the incidence of hypertensive retinopathy was 10.7% (from 12,751 persons) with a median follow-up time of 8.6 years [2] A study in DR. M. Djamil Hospital, Padang, Indonesia, found that hypertensive retinopathy was present in 66.67% hypertensive patients [3] Chronic kidney disease (CKD) was found to be the most significant factor to predict severe hypertensive retinopathy [4] Erden S, Bicakci E. Hypertensive retinopathy: incidence, risk factors, and comorbidities. Clin Exp Hypertens. 2012;34(6):397-401 Alexander Karl-Georg Schuster, Stella Hoh, Karl Neubert, Ahmad Haj Ibrahim, Stefan Nickels, Christina A. Korb, Andreas Schulz, Thomas Muenzel, Matthias Michal, Irene Schmidtmann, Karl Lackner, Philipp Wild, Norbert Pfeiffer; Prevalence of hypertensive retinopathy and its risk for mortality – results from the Gutenberg Health Study. Invest. Ophthalmol. Vis. Sci. 2020;61(7):1308. Rahman K, Yusticia RY. Profil Retinopathy Hipertensi di Rumah Sakit Dr. M Djamil Padang . J Kesehat Andalas . 2018;7(Supplement 1):19. . Kabedi NN, Mwanza JC, Lepira FB, Kayembe TK, Kayembe DL. Hypertensive retinopathy and its association with cardiovascular, renal and cerebrovascular morbidity in Congolese patients. Cardiovasc J Afr. 2014 Sep-Oct;25(5):228-32.

4. PATOPHYSIOLOGY Retinal blood vessels have distinct features that differentiate them from other blood vessels, including: [1] The absence of sympathetic nerve supply Local autoregulation of blood flow Presence of blood-retinal barrier A n increase in systemic BP is transferred directly to the to the vessels which initially constrict. A further increase in BP overcomes this compensatory tone and damage to the muscle layer and endothelium ensues . Blood pressure elevation continues Hypertensive retinopathy goes through 3 phases: vasoconstrictive, sclerotic, and exudative phases [2] Chaine G, Kohner EM. [Hypertensive retinopathy]. J Fr Ophtalmol. 1983;6(12):995-1005. Modi, P., Arsiwalla, T. Hypertensive retinopathy [Internet]. StatPearls Publishing. 2021 [Accessed on 22 February 2022]. Available on: https://www.ncbi.nlm.nih.gov/books/NBK525980/

5. 3 PHASES OF HYPERTENSIVE RETINOPATHY Vasoconstrictive Phase The local autoregulatory mechanisms come into play This autoregulatory mechanisms cause vasospasm and retinal arteriole narrowing, which is evident by the decrease in the arteriole to venule ratio (Normal = 2:3). Sclerotic Phase Persistent elevated BP cause changes in vessel wall These changes include: Thickening of the intimal layer Hyperplasia of the media layer Hyaline degeneration of the arteriolar wall Exudative Phase Disruption of the blood-brain barrier and leakage of plasma and blood into the vessel wall Typically seen in severely increased BP patients Leakage of plasma and blood into the vessel wall cause disruption in the local autoregulatory mechanism C ausing retinal hemorrhages ( flame-shaped and dot blot ), hard exudates, retinal ischemia ( cotton-wool spots ), and necrosis of smooth muscle. Leads to a severe form of arteriolar narrowing, arteriovenous (AV) crossing changes , and widening and accentuation of light reflex ( silver and copper wiring ) Modi, P., Arsiwalla, T. Hypertensive retinopathy [Internet]. StatPearls Publishing. 2021 [Accessed on 22 February 2022]. Available on: https://www.ncbi.nlm.nih.gov/books/NBK525980/

6. DIAGNOSIS Diagnosis based upon its clinical appearance on dilated fundoscopic exam and coexistent hypertension [1,2] HISTORY OF HYPERTENSION Focus on disease history, symptoms of hypertension, and its complications Most patients are asymptomatic Symptoms : headaches*, eye pain*, reduced visual acuity* , focal neurological deficits, chest pain, shortness of breath, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, and palpitation Complications : history of stroke/transient ischemic attack, coronary or peripheral vascular disease, and heart failure PHYSICAL EXAMINATION Focus on vital signs (especially blood pressure) and dilated fundoscopy Fundus exam is necessary for staging of hypertensive retinopathy Modi, P., Arsiwalla, T. Hypertensive retinopathy [Internet]. StatPearls Publishing. 2021 [Accessed on 22 February 2022]. Available on: https://www.ncbi.nlm.nih.gov/books/NBK525980/ American Academy of Ophthalmology. Hypertensive retinopathy [Internet]. 2021 [Accessed on 22 February 2022]. Available on: https://eyewiki.aao.org/Hypertensive_Retinopathy#Diagnosis * Symptoms of acute malignant hypertension

7. FUNDOSCOPIC FEATURES AV crossing changes [1] Salus’s sign: retinal vein deflection as it crosses the arteriole Gunn’s sign: retinal vein tapering on either side of the AV crossing Bonnet’s sign: banking of retinal vein distal to the AV crossing Modi, P., Arsiwalla, T. Hypertensive retinopathy [Internet]. StatPearls Publishing. 2021 [Accessed on 22 February 2022]. Available on: https://www.ncbi.nlm.nih.gov/books/NBK525980/ Epomedicine. Hypertensive Retinopathy Grading – Simplified [Internet]. Epomedicine; 2019 Jun 1 [cited 2022 Feb 19]. Available from:  https://epomedicine.com/medical-students/hypertensive-retinopathy-grading-simplified/ . Figure 1. AV crossing changes [2]

8. Arterial Changes [1] Decrease in AV ratio to 1:3 (normal ratio 2:3) Change in the arteriolar light reflex (copper and/or silver wiring) Figure 2. Copper-wiring, arteriovenous nicking and silver-wiring seen in a patient with hypertensive retinopathy [2] Modi, P., Arsiwalla, T. Hypertensive retinopathy [Internet]. StatPearls Publishing. 2021 [Accessed on 22 February 2022]. Available on: https://www.ncbi.nlm.nih.gov/books/NBK525980/ American Academy of Ophthalmology. Hypertensive retinopathy [Internet]. 2021 [Accessed on 22 February 2022]. Available on: https://eyewiki.aao.org/Hypertensive_Retinopathy#Diagnosis

9. NORMAL A/V RATIO (2:3) Point of measurement for the A/V ratio: One disc diameter away from the optic nerve, around the second bifurcation Schramm Od Cns Fsls, Nathan. (2019). Re: How to find the avr ratio?. Retrieved from: https://www.researchgate.net/post/How-to-find-the-avr-ratio/5d8d4a0bd7141b9cc85eff2a/citation/download. Figure 3. Normal A/V ratio

10. ARTERIOLE DECREASED A/V RATIO (1:3) VENULE Modi, P., Arsiwalla, T. Hypertensive retinopathy [Internet]. StatPearls Publishing. 2021 [Accessed on 24 February 2022]. Available on: https://www.statpearls.com/ArticleLibrary/viewarticle/35600 Figure 4. Decreased A/V ratio

11. Retinal Changes [1] Retinal hemorrhages Dot-blot hemorrhages Bleeding in the inner retinal layer Flame shaped hemorrhage Bleeding in the superficial retinal layer Retinal exudates Hard exudate Lipid deposits in the retina Soft exudate Ischemia of the nerve fibers ( cotton wool spots ) Figure 5. AV crossing changes, macular star, and cotton wool spots [2] Modi, P., Arsiwalla, T. Hypertensive retinopathy [Internet]. StatPearls Publishing. 2021 [Accessed on 22 February 2022]. Available on: https://www.ncbi.nlm.nih.gov/books/NBK525980/ American Academy of Ophthalmology. Hypertensive retinopathy [Internet]. 2021 [Accessed on 22 February 2022]. Available on: https://eyewiki.aao.org/Hypertensive_Retinopathy#Diagnosis Macular Changes [1] Formation of macular star due to deposition of hard exudates around the macula.

12. Figure 6. Features of hypertensive retinopathy [2] American Academy of Ophthalmology. Hypertensive retinopathy [Internet]. 2021 [Accessed on 22 February 2022]. Available on: https://eyewiki.aao.org/Hypertensive_Retinopathy#Diagnosis Kulenkamp, E. Hypertensive retinopathy [Internet]. Available on: http://morancore.utah.edu/basic-ophthalmology-review/hypertensive-retinopathy/ Optic Nerve Changes [1] Hypertension may lead to optic neuropathy (specifically presents as optic disk swelling) Signs of optic neuropathy are: Flame shaped hemorrhage at the disc margin Blurred disc margin Congested retinal vein Papilledema Secondary macular exudates

13. MODIFIED SCHEIE CLASSIFICATION OF HYPERTENSIVE RETINOPATHY [1] American Academy of Ophthalmology. Hypertensive retinopathy [Internet]. 2021 [Accessed on 22 February 2022]. Available on: https://eyewiki.aao.org/Hypertensive_Retinopathy#Diagnosis Epomedicine . Hypertensive Retinopathy Grading – Simplified [Internet]. Epomedicine ; 2019 Jun 1 [cited 2022 Feb 19]. Available from:  https://epomedicine.com/medical-students/hypertensive-retinopathy-grading-simplified/ . Grade 0: No changes Grade 1: Barely detectable arterial narrowing Grade 2: Obvious arterial narrowing with focal irregularities Grade 3: Grade 2 + retinal hemorrhages, exudates, cotton wool spots, or retinal edema Grade 4: Grade 3 + papilledema Figure 7. Grade 3-4 of hypertensive retinopathy [2]

14. MODIFIED SCHEIE CLASSIFICATION OF HYPERTENSIVE RETINOPATHY Walsh JB et al. Chapter 13: Systemic Hypertension and the Eye. [Internet]. 2022. Available from: http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v3/v3c013.html A.  Grade I narrowing of the arterioles B.  Grade II: generalized narrowing, focal constriction, arteriolar sclerosis with widening of the reflex stripe.  C.  Grade III: generalized narrowing, focal constriction, hemorrhages, and exudate, arteriolar sclerosis with widening of the light reflex.  D.  Grade IV: generalized narrowing, focal constriction, hemorrhages, and exudates and edema of the disc with arteriolar sclerosis.  Figure 8. Funduscopic findings based on Modified Scheie Classification [2]

15. KEITH-WAGENER-BARKER CLASSIFICATION [1] Grade 1: Mild, generalized constriction of retinal arterioles Grade 2: Definite focal narrowing of retinal arterioles + AV nicking (arrows) Grade 3: Grade 2 + flame-shaped hemorrhages + cotton-wool spots + hard exudates Grade 4: Severe Grade 3 retinopathy + papilledema or retinal edema Figure 9. Funduscopic findings based on Keith-Wagener-Barker Classification [2] American Academy of Ophthalmology. Hypertensive retinopathy [Internet]. 2021 [Accessed on 22 February 2022]. Available on: https://eyewiki.aao.org/Hypertensive_Retinopathy#Diagnosis Anonymous. Hypertensive retinopathy [Internet]. [Accessed on 24 February 2022]. Available on: https://basicmedicalkey.com/hypertensive-retinopathy-2/

16. WONG AND MITCHELL CLASSIFICATION OF HYPERTENSIVE RETINOPATHY Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004;351:2310–2317. doi:10.1056/NEJMra032865 Aissopou EK, Papathanassiou M, Nasothimiou EG, Konstantonis GD, Tentolouris N, Theodossiadis PG, Papaioannou TG, Sfikakis PP, Protogerou AD. The Keith-Wagener-Barker and Mitchell-Wong grading systems for hypertensive retinopathy: association with target organ damage in individuals below 55 years. J Hypertens. 2015 Nov;33(11):2303-9. doi: 10.1097/HJH.0000000000000702. PMID: 26335430. Mitchell-Wong seems preferable to the Keith-Wagener-Barker classification system, for reasons of simplifying clinical practice and the grades of retinopathy were more strongly associated with systemic issues [1,2]

17. DIFFERENTIAL DIAGNOSIS Conditions that have similar features with hypertensive retinopathy includes most notably diabetic retinopathy , radiation retinopathy , and retinal vein occlusion [1] CLINICAL FINDINGS HYPERTENSIVE RETINOPATHY DIABETIC RETINOPATHY RADIATION RETINOPATHY History History of hypertension History of diabetes History of radiation (e.g. nasopharyngeal carcinoma treatment) [2,3] Funduscopic Findings AV changes Arterial changes Retinal changes Macular changes Optic nerve changes Similar findings with hypertensive retinopathy Similar findings with hypertensive retinopathy Optic disc edema can also be found in diabetic papillopathy, anterior ischemic optic neuropathy, and neuroretinitis [1] American Academy of Ophthalmology. Hypertensive retinopathy [Internet]. 2021 [Accessed on 22 February 2022]. Available on: https://eyewiki.aao.org/Hypertensive_Retinopathy#Diagnosis Ho, IV. Radiation retinopathy [Internet]. 2012 [Accessed on 24 February 2022]. Available on: http://www.retina.com.au/case-of-the-monthdec-2012/ Raja V, Rajagopalan S, Kashab T, Moriarty B. Radiation retinopathy: a mistaken diagnosis of hypertensive retinopathy. Clinical and Experimental Optometry. 2007;90(6):468-470.