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Hypertensive retinopathy is damage to the retina and retinal circulation due to high blood pressure (i.e. hypertension). Hypertension - a very common misfortune in the United States, almost uncommon to not have it once a certain age is hit. Hypertension is most directly linked to the kidneys, the heart, periphery vessels, coronary vessels,etc. However, hypertension affects the eyes as well. Specifically, changes in the retinal and choroidal vasculature when severe hypertension hits. “Severe hypertension” refers to a severe acute case, a hypertensive crisis - where blood pressure is way over that 180/110 range or a patient with chronic hypertension - an older aged person that has been taking lisinopril for the last twenty years for mild hypertension. Surprisingly, both of these cases will affect the eyes similarly.

Affects both retinal and choroidal circulation. Retinal circulation is more towards the inner globe of the eye and that feeds the inner parts of the retina. The choroidal circulation feeds the very outer retina.

The retinal vasculature is autoregulated. It means that when a systemic blood pressure goes up or down the retinal vasculature can expand or contract to keep the blood pressure in the retinal vasculature at a set rate - like a thermostat. When the blood pressure goes too high (specifically exceeds 110-115 mmHg) the vasculature can no longer autoregulate itself. When the systemic blood pressure goes up, the response of the retinal vasculature is going to be to expand. If blood pressure goes down, the retinal vasculature is going to constrict to maintain a normal blood pressure range.

On the other hand, the choroidal vasculature is regulated in part by the sympathetic nervous system.

Primarily seen in older patients because they make up the vast majority of hypertensive patients.

Two distinct disease processes:


 * 1) Acute Hypertensive Retinopathy: May be seen in patients of any age due to sudden severe hypertension - where blood pressure is over the 180/110 range.
 * 2) Chronic Hypertensive Retinopathy: Seen in older patients because older patients tend to have hypertension. Hypertension accelerates the process of atherosclerosis. With atherosclerosis, retinal arterioles expand and compress venules which may lead to occlusion. - problematic.

Acute Hypertensive Retinopathy

Also referred to as malignant hypertensive retinopathy.

Acute hypertensive retinopathy is typically seen as a hypertensive crisis. Generally blood pressure (BP) must be over 200/110 to cause retinopathy.


 * Causes of secondary hypertension include: hyperthyroidism, pherocromocytoma,       pre-eclampsia/eclampsia, drug abuse, neoplasia

Elevated blood pressure (BP) causes direct damage to retinal and choroidal vasculature (fibrinoid necrosis) and subsequently ischemic necrosis. This manifests as:


 * Cotton-wool spots: ischemia to nerve fibers
 * Uniform narrowing of arterioles; tortuiosity
 * Flame hemorrhages, dot-blowing hemorrages: Necrosis, bleeding
 * Papilledema: Leakage from arterioles supplying optic disk
 * Elsching spots: Damage to RPE
 * Treatment (Acute hypertensive Retinotherapy)

Clinical/Ophthalmoscopic exam; the underlying cause should be sought based upon the patient’s history.

Manage the underlying cause - cautious of not reducing BP too precipitously - can worsen damage.

Common complications:

Retinal detachment: Due to damage to, exudations in choroid/RPE. Acute change in vision (peripheral), photopsia, floaters.

Optic neuropathy: Ischemia of the optic nerve head due to vasoconstriction. Blurred disk margin, papilledema, flame hemorrhages.

Chronic Hypertensive Retinotherapy

Chronic hypertension accelerates the development of atherosclerosis. In advanced form, acuity loss will be present.

End organ disease manifestation of hypertension.

Contents

 * 1Signs and symptoms
 * 1.1Signs
 * 2Pathophysiology
 * 3Diagnosis
 * 3.1Differential Diagnoses
 * 3.2Keith Wagener Barker (KWB) Grades
 * 4Management
 * 5See also
 * 6References
 * 7Further reading
 * 8External links

Signs and symptoms[edit source]
Most patients with hypertensive retinopathy have no symptoms. However, some may report decreased or blurred vision,[1] and headaches.[2]

Signs[edit source]
Signs of damage to the retina caused by hypertension include:


 * Arteriolar changes, such as generalized arteriolar narrowing, focal arteriolar narrowing, arteriovenous nicking, changes in the arteriolar wall (arteriosclerosis) and abnormalities at points where arterioles and venules cross. Manifestations of these changes include Copper wire arterioles where the central light reflex occupies most of the width of the arteriole and Silver wire arterioles where the central light reflex occupies all of the width of the arteriole, and "arterio-venular (AV) nicking" or "AV nipping", due to venous constriction and banking.

Arterioscleorsis increases rigidity, hardening and loss of elasticity of small vessel walls, manifested most obviously at AV crossing points.

Presence of arteriosclerosis indicates that hypertension has been present for many years even if blood pressure (BP) is currently controlled.


 * advanced retinopathy lesions, such as microaneurysms, blot hemorrhages and/or flame hemorrhages, ischemic changes (e.g. "cotton wool spots"), hard exudates and in severe cases swelling of the optic disc (optic disc edema), a ring of exudates around the retina called a "macular star" and visual acuity loss, typically due to macular involvement.

Mild signs of hypertensive retinopathy can be seen quite frequently in normal people (3–14% of adult individuals aged ≥40 years), even without hypertension.[3] Hypertensive retinopathy is commonly considered a diagnostic feature of a hypertensive emergency although it is not invariably present.[4]

Pathophysiology[edit source]
The changes in hypertensive retinopathy result from damage and adaptive changes in the arterial and arteriolar circulation in response to the high blood pressure.[1]

Differential Diagnoses[edit source]
Several other diseases can result in retinopathy that can be confused with hypertensive retinopathy. These include diabetic retinopathy, retinopathy due to autoimmune disease, anemia, radiation retinopathy, and central retinal vein occlusion.[2]

Keith Wagener Barker (KWB) Grades[edit source]
Grade 1

Vascular Attenuation

-Mild generalised arteriolar narrowing

-This is the first response (?) of retinal arterioles to systemic hypertension

Grade 2

As grade 1 + Irregularly located, tight constrictions – Known as "AV nicking" or "AV nipping" – Salus's sign

-Focal arteriolar narrowing

-Arteriovenous nipping (squeezing)

-Copper wiring appearance of arteriolar wall

Grade 3

As grade 2 + Retinal edema, cotton wool spots and flame-hemorrhages "Copper Wiring" + Bonnet's Sign + Gunn's Sign

Grade 4

As grade 3 + optic disc edema + macular star "Silver Wiring"

There is an association between the grade of retinopathy and mortality. In a classic study in 1939 Keith and colleagues[5] described the prognosis of people with differing severity of retinopathy. They showed 70% of those with grade 1 retinopathy were alive after 3 years whereas only 6% of those with grade 4 survived.The most widely used modern classification system bears their name.[3] The role of retinopathy grading in risk stratification is debated, but it has been proposed that individuals with signs of hypertensive retinopathy signs, especially retinal hemorrhages, microaneurysms and cotton-wool spots, should be assessed carefully.[3]

Management[edit source]
A major aim of treatment is to prevent, limit, or reverse target organ damage by lowering the person's high blood pressure to reduce the risk of cardiovascular disease and death. Treatment with antihypertensive medications may be required to control the high blood pressure.

See also[edit source]

 * Hypertensive crisis
 * List of eye diseases and disorders
 * List of systemic diseases with ocular manifestations
 * Ophthalmology
 * Optometry

References[edit source]

 * ^ Jump up to:a b Bhargava, M; Ikram, M K; Wong, T Y (2011). "How does hypertension affect your eyes?". Journal of Human Hypertension. 26 (2): 71–83. doi:10.1038/jhh.2011.37. PMID 21509040.
 * ^ Jump up to:a b Yanoff, Myron; Duker, Jay S. (2009-01-01). Ophthalmology. Elsevier Health Sciences. ISBN 0323043321.
 * ^ Jump up to:a b c Wong TY, Mcintosh R (2005). "Hypertensive retinopathy signs as risk indicators of cardiovascular morbidity and mortality". British Medical Bulletin. 73-74: 57–70. doi:10.1093/bmb/ldh050. PMID 16148191.
 * Jump up^ Cremer, A.; Amraoui, F.; Lip, G. Y. H.; Morales, E.; Rubin, S.; Segura, J.; Van den Born, B. J.; Gosse, P. (2016-08-01). "From malignant hypertension to hypertension-MOD: a modern definition for an old but still dangerous emergency". Journal of Human Hypertension. 30(8): 463–466. doi:10.1038/jhh.2015.112. ISSN 0950-9240.
 * Jump up^ Keith NM, Wagener HP, Barker NW (1939) Some different types of essential hypertension: their course and prognosis. Am J Med Sci, 197, 332–43.