Hypertensive Retinopathy,new.pptx . Bangladesh

Details about hypertension and hypertensive retinopathy

1. Management of Hypertensive Retinopathy

2. Blood Pressure? Lateral pressure of blood exerted on wall of the blood vessels Hypertension?: Elevated Blood Pressure >140/90 mm Hg

3. Malignant Hypertension Extremely high blood pressure Develops rapidly Causes end organ damage >180/120 mm Hg

4. Target organs of hypertension:

5. Hypertensive Retinopathy Damage of retina and retinal vasculatures due to Elevated blood pressure Bilateral Symmetrical Small blood vessels

6. Pathophysiology

7. Retinal circulation Arterial system Central retinal artery Arterioles Capillaries Venous system Small venules Large venules Veins

8. Vasoconstrictive Phase

9. Fig : Vasoconstrictive phase

10. Sclerotic phase Silver or Copper wiring A-V nipping

11. Fig : Sclerotic phase

12. Exudative Phase Retinal nerve fiber layer ischemia Retinal hemorrhage, hard exudates , cotton wool spots Exudation of blood, accumulation of Lipids

13. Fig : Exudative Phase

14. Malignant Hypertension Phase

15. FF Fig : Malignant phase

16. Hypertensive Retinopathy occurs under circumstance (A) Simple HTN without sclerosis - Young pt -signs .Focal/ generaslized constriction of arteriols .Flame shape hge .CWS may present

17. (B) HTN with involutional sclerosis - Older pt - Arteriosclerosis retinopathy - Systemic features – CVS, Renal, Cerebrovascular - Ophthalmic – . Generalized arteriolar attenuation . A-V nipping . Flame shape hge , hard exudate, retinal oedema , macular star

18. ( C) Arteriolar/ Diffuse sclerosis - Young pt - Chronic glomerulonephritis with renal retinopathy - Vessels narrowing, tortous & nicking A-V crossing - Hge , exudate, CWS, Oedema

19. (D) Malignant / Accelerated HTN -Headache - Accelerated end organ damage . MI . Stroke . Renal failure

20. Classification Grade Description Grade 1 Slight narrowing, sclerosis, and tortuosity of the retinal arterioles; mild, asymptomatic hypertension Grade 2 Definite narrowing, focal constriction, sclerosis, and AV nicking; blood pressure is higher and sustained; few, if any, symptoms referable to blood pressure Grade 3 Retinopathy (cotton-wool patches, arteriolosclerosis, hemorrhages ); blood pressure is higher and more sustained; headaches, vertigo, and nervousness; mild impairment of cardiac, cerebral, and renal function Grade 4 Neuroretinal edema , including papilledema ; Siegrist streaks, Elschnig spots; blood pressure persistently elevated; headaches, asthenia, loss of weight, dyspnea , and visual disturbances; impairment of cardiac, cerebral, and renal function Keith-Wagener-Barker classification

21. Grading M odified Scheie classification Grade No change Grade 1 Barely detectable arterial narrowing Grade 2 Obvious arteriolar narrowing + A-V nipping +/- Copper wiring Grade 3 Grade 2 + Retinal hemorrhages +/- Exudates Grade 4 Grade 3 + Disc swelling

22. Gunn’s sign Bonnet’s sign

23. Diagnosis History Taking Symptoms Signs Ocular General Clinical Diagnosis Grading Investigations Ocular General

24. History Taking : H/O-Systemic Hypertension Duration Severity Drug history Family History Any other systemic diseases? Occupation Exercise Alchohol /Smoking? Complications TIA,Stroke,PVD,Heart failure

25. Symptoms: Usually asymptomatic In aged individuals History of Hypertension If with Malignant Hypertension Eye ache Headache Decreased Visual acuity

26. Ocular signs Visual acuity: reduced Pupil RAPD Anterior segment Assessment. IOP measurement

27. Posterior segment evaluation:

28. General Examination Vital Signs Cardiovascular Examination Pulmonary Examination Neurological Examination

29. Investigations: Ocular: Colour Fundus Photography : Arteriolar narrowing A-V nipping Cotton wool spots Exudates Flame Shaped Hemorrhage Disc swelling OCT: T o exclude edema.

30. Investigations: Fluorescein Angiography: Acute Hypertension : Retinal capillary non perfusion Microaneurysm formation Chronic Hypertension: Diffuse leakage

31. Indocyanine Green Angiography: Moth eaten appearance in Malignant Hypertension

32. Investigations Blood sugar HbA1C Lipid Profile Cardiac evaluation – ECG ECHO Renal function test Sleep Study-Obstructive sleep apnea

33. Differential Diagnosis Diabetic Retinopathy CRVO BRVO Ocular ischemic syndrome

34. Fig :Diabetic Retinopathy

35. Fig:CRVO

36. Fig:Ocular Ischemic Syndrome

37. Management A major aim of treatment is to prevent, limit, or reverse such target organ damage by lowering the patient's high blood pressure Advice patient to reduce the Blood Pressure - . Taking the medication accordingly . Referral to medical team

38. Medical Management Control of Systemic Hypertension: <140/90mmhg Chronic Hypertension: ACE inhibitors Calcium channel blockers Beta Blockers Diuretics

39. Malignant Hypertension: Slow , Deliberate , Progressive control Rapid Control

40. If complication develops : CRAO CRVO BRVO NAION Pre retinal hge Treatment according to cause. Patient Counseling: Life style modification Regular exercise Healthy diet Regular follow up Regular follow up.

41. Fig - NAION

42. Fig – Pre retinal hge

43. Prognosis: Severe visual loss rare in chronic disease. By proper treatment retinal damage can be halted. But , Arteriolar changes once occur its permanent. Hypertensive retinopathy+arteriosclerotic changes =Increased risk for Coronary diseases,Stroke,PVD etc. Malignant Hypertension , if controlled =Retinal changes improves. Damage to optic nerve + macula =Long term vision loss.

44. Primary Prevention : Healthy life style Healthy Diet Regular Exercise Secondary Prevention; Proper treatment Regular Drug intake Regular follow up

45. T Take home message!

46. OCULAR MENIFESTATIONS SYSTEMIC DISEASE