Hypertensive Retinopathy

Question 1

what is hypertensive retinopathy?

Answer 1

Hypertensive retinopathy is an eye condition caused by high blood pressure. Over time, high blood pressure can damage the blood vessels in the eyes and affect eyesight.

Question 2

How do you tell if hypertensive retinopathy is malignant or not?

Answer 2

they say it is malignant when the optic disc is involved

Question 3

What happens as a result of hypertension?

Answer 3

changes in the structure and function of the micro-vessels and large vessels.
this can then manifest into:
hypertensive retinopathy
hypertensive choroidopathy
hypertensive neuropathy

Question 4

What is the main blood supply to the eye?

Answer 4

common carotid artery > internal carotid artery > ophthalmic artery > orbital/ocular divisions

Question 5

What are the five ophthalmic artery divisions?

Answer 5

1. central retinal artery
2. long posterior ciliary artery
3. short posterior ciliary artery
4. anterior ciliary artery (arises from musc artery)
5. muscular artery

Question 6

What are the two sources of blood supply to the retina?

Answer 6

1. the central retinal artery supplies the blood to the inner retina.
2. The choroidal blood vessels supplies blood to the outer retina.

Question 7

Why is hypertension detrimental to vascular health?

Answer 7

increased BP changes the small arteries and increases peripheral vein resistance, leading to vasoconstriction, which makes them narrow and increases BP.
Endothelial dysfunction can occur leading to oxidative stress and therefore to inflammation. end dysf can cause the whole vascular supply to any target organ to be affected and if left untreated then the target organ can be damaged

Question 8

What is atherosclerosis?

Answer 8

a disease of the arteries to arterioles results:
in stiffened/thickened wall
narrow arteriolar lumen
raised BP
breakdown of elastic leading to arteriosclerosis and if left untreated or uncontrolled it results in endothelial dysfunction

Question 9

What is ischaemia?

Answer 9

when the heart undergoes changes, so does the blood vessels. They show increase in collagen, media thickness and lumen, which increases the aortic stiffness. The stiffness leads to increase in perfusion pressure. If left untreated, this affects diastolic BP, decreases perfusion and leads to ischaemia

Question 10

What are the signs of hypertensive retinopathy?

Answer 10

AV narrowing
focal changes
venous nicking/banking
silver wiring
micro aneurysms
cotton wool spots
dot, blot and flame haemorrhages
exudate and transudate
choroidopathy
acute disc swelling

Question 11

Exudate vs transudate?

Answer 11

exudates are fluids, cells or other cellular substances that slowly discharge from blood vessels usually from inflamed tissues.

transudates are fluids that pass through a membrane or squeeze through tissue or into the extracellular space of tissues. Transudates are thin and watery and contain few cells or protein.

Question 12

What is the normal AV ratio?

Answer 12

normal ratio is 2:3 but if you see the ratio down to less than 2:3 (poss 1:3) consider AV narrowing

Question 13

What is focal AV narrowing?

Answer 13

in respone to acute rise in BP the vessels spasms, causing focal narrowing.
Localised oedema can cause this.
Focal narrowing is a sign of acute hypertension

Question 14

AV nicking/nipping?

Answer 14

this is a sign of hypertensive retinopathy?
you have to talk to them about hypertension (if they aren’t on meds already)
“have you had your BP checked recently?”

Question 15

What is copper wiring?

Answer 15

the thickening and hyperplasia of smooth muscle cells become more reflective and glossy (hyalinised).
the increased thickness of the vessel walls causes the reflex to be more diffuse and less bright due to progression of sclerosis and hyalination and the retinal arterioles appear orange-brown

Question 16

What is silver wiring?

Answer 16

this is the later stage where if the blood vessels continue to thicken, the blood column becomes less visible and gets more hyalinised or glossy giving a silver wire appearance.

Question 17

What is hypertensive choroidopathy (chorioretinopathy)?

Answer 17

Hypertensive choroidopathy, usually seen in combination with hypertensive retinopathy and termed hypertensive chorioretinopathy, is often seen in younger patients who have acute elevations in blood pressure. Hypertensive choroidopathy is characterized by fibrinoid necrosis of choroidal arterioles, with resultant non-perfusion of the overlying choriocapillaris and focal ischemic damage to the retinal pigment epithelium (RPE).6 Areas of focal ischemia appear as yellowish lesions at the level of the RPE, called Elschnig spots. Over time, these become irregularly pigmented with a depigmented halo. Ischemia along choroidal lobules appear as linear hyperpigmented streaks along the course of underlying choroidal arteries, called Siegrist streaks. Macular oedema is often present. When blood pressure is severely elevated, global choroidal dysfunction affects the pumping capacity of the RPE, which leads to serous retinal or RPE detachments.

Question 18

What are focal intraretinal
periarteriolar transudates?

Answer 18

Small white focal lesions in the
deeper layers of the retina
caused by ischaemia and loss
of blood retina barrier.
Due to Hydrostatic forces the
fluid comes out of vessels

Question 19

What is papilloedema?

Answer 19

High BP increases intracranial
blood pressure which results
BILATERAL disc swelling occurs
when the hypertension is severe
enough. Papilloedema is an emergency (likely ~200mmHg systolic).
* malignant hypertension and needs
hospitalisation and needs immediate
resolution of BP

Question 20

Acute vs chronic hypertension?

Answer 20

Acute:
* Focal arteriolar narrowing
* Haemorrhages
* Microaneurysms
* Cotton Wool spots
* Disc Swelling
* Hard exudate

Chronic:
* Generalised arteriolar narrowing
* AV crossing changes
* Copper wiring
* Silver wiring

Question 21

How do you classify hypertensive retinopathy?

Answer 21

using the Keith-Wagner-Barker classification (most common) or the Scheie classification (least common)

Question 22

What is the resolution of hypertensive retinopathy?

Answer 22

Arteriosclerotic changes: persists after the hypertension is treated.
Haemorrhages: over several weeks after treatment.
Cotton wool spots: after 10-12 weeks of treatment.
Disc swelling: over several months.
Macular stars: over a year to resolve.

Question 23

What are the consequences of hypertensive retinopathy?

Answer 23

hypertensive px’s are at risk of an CRAO because of the greater risk of emboli from atherosclerotic plaque rupture. also a greater risk of vein occlusions because of abnormal blood flow, vascular function and thrombosis

Question 24

How to manage hypertensive retinopathy?

Answer 24

determine whether it is acute or chronic
extensive history taking, making sure you ask about: meds (number,dose,changes), BP measurements, systemic disease.
if there is disc involvement, or VA loss REFER!

Question 25

How do you differentiate hypertensive retinopathy with diabetic retinopathy?

Answer 25

the risk factors are very similar for both.
flame haemorrhage is associated with hypertension; dot and blot are less likely.
Hypertension = CWS, haems (some), little exudates/oedema

Question 26

What happens in chronic, acute, severe and malignant hypertensive retinopathy?

Answer 26

Chronic= generalised narrowing
Acute= focal narrowing, haems, CWS
Severe= exudate, transudate, choroidopathy
Malignant= papilloedema