Hypertensive retinopathy.pptx for post graduates

this hypertensive retinopathy ppt is very useful for postgraduates. its easy and lucid language is the key to understand the various terminologies

1. Hypertensive Retinopathy

2. Definition Fundus changes occuring in patients suffering from systemic hypertension is called as Hypertensive retinopathy

3. Hypertensive Retinopathy Prevalence Symptoms Diagnostic techniques and signs Pathophysiology Associated conditions Management

4. Hypertensive Retinopathy - Introduction Bilateral Symmetrical Small blood vessel disease Caused by systemic hypertension Acute or chronic Systolic or diastolic End organ disease manifestation

5. Hypertensive Retinopathy - Prevalence The second most common retinal vascular disease Systemic hypertension (>160/90mmHg) 10-15% in the UK >40 age group Malignant hypertension (240/140mmhg) 0.5-0.75% Hypertensive retinopathy 4-10%

6. Hypertensive Retinopathy – Prevalence, Risk factors Afro-Caribbeans = relative risk factor 2x Age Family history Medications Obesity Smoking Stress Alcohol consumption Lack of exercise

7. Hypertensive Retinopathy – Prevalence, Morbidity Risk Stroke (7x) Heart attack (4x) Coronary artery disease (3x) Peripheral artery disease (2x)

8. Pathogenesis Vasospasm: Arteriolar narrowing Arteriosclerotic changes: changes in arteriolar reflex & AV nipping due to thickening of vessel wall Increased vascular pemeability results from hypoxia causing breakdown of blood retinal barrier Raised intracranial pressure in malignant hypertension

9. Hypertensive Retinopathy – History & Symptoms Possible history of systemic hypertension Systemic hypertension largely asymptomatic Hypertensive retinopathy largely asymptomatic The eye examination will often give the first clue of systemic hypertension

10. Clinical features Benign or chronic hypertensive retinopathy Malignant hypertensive retinopathy

11. Hypertensive Retinopathy – Diagnostic Techniques & Signs Ophthalmoscopy (non-malignant retinopathy) Arteriosclerosis from chronic disease focal arteriolar narrowing arterio-venous crossing changes venous constriction and deflection distal banking arteriolar colour changes vessel sclerosis Similar signs with ageing Sphygmomanometry blood pressure measurement is required to make a positive diagnosis in the absence of malignant retinopathy changes

12. Hypertensive Retinopathy – Diagnostic Techniques & Signs Arteriolar Narrowing Young patients, autoregulation causes uniform narrowing of retinal arterioles Older patients, arteriosclerosis and autoregulation cause focal arteriolar narrowing Assess the arterio-venous calibre ratio as a percentage adjacent arteries and veins equivalent numbers of bifurcations between 1 and 3 DD from optic disc

13. Hypertensive Retinopathy – Diagnostic Techniques & Signs Generalised narrowing of the retinal arterioles

14. Hypertensive Retinopathy – Diagnostic Techniques & Signs Focal narrowing of the retinal arterioles – Copper and Silver Wiring

15. Hypertensive Retinopathy – Diagnostic Techniques & Signs Arteriosclerosis Thickening of the arteriolar wall Assess using the arteriolar reflex brightness thickness ratio Assess using arterio-venous crossing changes venous deflection (Salus’ sign) Tapering of veins on either side (nipping; Gunn’s sign ) venous distal banking (Bonnet’s sign)

16. Hypertensive Retinopathy – Diagnostic Techniques & Signs Gunn’s sign & right-angled crossing Bonnet’s sign

17. Hypertensive Retinopathy – Diagnostic Techniques & Signs Gunn’s sign, right-angled crossing & Bonnet’s sign Salus’ sign?

18. Hypertensive Retinopathy – Diagnostic Techniques & Signs Malignant Hypertensive Retinopathy A:V ratio of 25% & arterial reflex ratio of 60% “copper wiring” A:V ratio of <20% & arterial reflex ratio of 100% “silver wiring” cotton wool spots hard exudates dot and flame shaped haemorrhages if advanced – retinal or macula oedema or papilloedema all non-advanced changes due to focal hypoperfusion note presence, number, size, position (photograph!)

19. Hypertensive Retinopathy – Diagnostic Techniques & Signs Early malignant Dot and blot haemorrhages Hard and soft exudates Diffuse arteriolar narrowing Arterio-venous crossing defects

20. Hypertensive Retinopathy – Diagnostic Techniques & Signs Advanced malignant Macular star Pailloedema

21. Hypertensive Retinopathy - Classification < 2 0% M a l i g na n t abnormalities encountered in Grades I through III, as well as swelling of the optic nerve head and macular star I V 2 5 % M a l i g na n t abnormalities seen in Grades I and II, as well as retinal haemorrhages, hard exudation, and cotton-wool spots I I I 3 3 % Non-malignant narrowing of the retinal arteries in conjunction with regions of focal narrowing and arterio-venous nipping I I 5 % Non-malignant minimal narrowing of the retinal arteries I A:V rat i o A l ternati v e descr i p t ion Desc r i p t i on G r ade ,

22. Keith Wagener Classification Grade I Mild generalised arteriolar attenuation of small branches & broadening of arteriolar light reflex Grade II Marked generalised narrowing with Salus sign Grade III Grade II + coppering wiring of arterioles+ Bonnet sign + Gunn sign,flame shaped haemorrhages,cotton wool spots,hard exudates. Grade IV Grade III +silver wiring+ papilloedema

23. Other classifications Modified Schele Grade 0 to Grade IV Mitchell Wong Classification

24. Hypertensive Retinopathy – Classification Grade 2

25. Hypertensive Retinopathy – Classification Grade 3

26. Hypertensive Retinopathy – Classification Grade 4

27. Hypertensive Retinopathy – Classification HR grades I and II are typically chronic HR grades III and IV are typically acute diastolic blood pressure >= 110 correlates with grade III diastolic blood pressure >= 130 correlates with grade IV

28. Hypertensive Retinopathy – Choroidopathy Hypertensive choroidopathy frequently occurs with grade IV Hypertensive Retinopathy yellow spots (Elshnig Nodules) are visible at the level of the retinal pigment epithelium hyperfluorescent on fluorescein angiography secondary to arteriosclerosis within the choriocapillaris in severe cases they cause serous retinal detachment resolve to become pigmented or depigmented linear groups of spots occur they are referred to as Siegrist's streaks

29. Hypertensive Retinopathy – Pathophysiology A disease of the retinal microvasculature Cholesterol deposition in the tunica intima of medium and large arteries reduction in the lumen size of these vessels Arteriolosclerosis causes a breakdown in autoregulation the high pressures in the arterioles are transmitted to the retinal capillaries capillary closure or haemorrhage occurs

30. Hypertensive Retinopathy – Pathophysiology Dot haemorrhages are ruptures of the deep capillary bed leakage of blood into the outer plexiform layer their depth leads to a round, small area of blood

31. Hypertensive Retinopathy – Pathophysiology Flame shaped haemorrhages are ruptures of the superficial capillary bed the blood disperses within the retinal nerve fibre layer Either capillary rupture or capillary closure

32. Hypertensive Retinopathy – Pathophysiology Arteriosclerotic changes persist after Tx Hypertensive retinopathy changes resolve over time following Tx Cotton wool spots develop in 24 to 48 hours with the elevation of blood pressure, and resolve in 2 to 10 weeks A macular star develops within several weeks of the development of elevated blood pressure and resolves within months to years Papilloedema develops within days to weeks of increased blood pressure and resolves within weeks to months Visual recovery is limited if the macula or optic nerve have been affected

33. Hypertensive Retinopathy – M a n a gement Appropriate treatment of the underlying hypertension If the patient is previously undiagnosed the patient needs referral to their general practitioner for assessment A grade I or grade II hypertensive retinopathy non-urgent referral A grade III hypertensive retinopathy more urgent referral to the GP A grade IV hypertensive retinopathy Px is in medical crisis. This patient needs immediate referral to a hospital eye casualty department

34. Hypertensive Retinopathy – Associated Conditions Branch retinal artery occlusion (BRAO) Central retinal artery occlusion (CRAO) Branch retinal vein occlusion (BRVO) Central retinal vein occlusion (CRVO) Non-arteritic anterior ischaemic optic neuropathy (NAION)

35. Hypertensive Retinopathy – Clinical Pearls If CWS are present, autoregulation has failed: diastolic BP >110mmHg Papilloedema means malignant hypertension BP > 250/150mmHg Fluorescein angiography is not indicated as it provides no diagnostic information

36. Hypertensive Retinopathy – Clinical Pearls Wet retina: multiple haemorrhages extensive oedema multiple exudates few cotton wool spots rare flame-shaped haemorrhages visibly abnormal retinal veins and capillaries Dry retina: few haemorrhages rare oedema rare exudate multiple cotton wool spots flame-shaped haemor r h a ges visibly abnormal retinal arteries Hypertensive Retinopathy Diabetic Retinopathy