From the Eye Clinic, Sehlgren’s Hospital Gothenburg, Sweden

The Nomenclature of Changes in the Fundus Oculi in Arterial Hypertension

BY

BENGT ROSENGREN

In the 1850-ties shortly after the invention of the ophthalmoscope cases with retinal haemorrhages and exudations were observed and further in- vestigations showed that albuminuria could nearly always be stated. The bad prognosis in these cases was remarkable as only a few per cent lived longer than two years. The prognostic import of the changes in the fundus attracted attention and the relation between the changes in the eye ground and disease of the kidneys seemed obvious. Hence the name of retinitis albuminurica.

The changes in the eye ground of quite another kind which began to be of interest in the 1890-ties are best known under the name of retinal arteriosclerosis. In these cases i t was the question of vascular changes in the retina which appeared as an irregularity of the lumen of the arteries, a general narrowing of these, an increase of the vascular reflex and especially the so called crossing phenomena, i. e. an apparent narrowing or a pressing back of the vein where an artery is passing over it. The cause was considered to be general arteriosclerosis.

At the change of the century blood pressure measuring was initiated as a standard method and as quite a lot of patients with hypertension had changes in their kidneys they were sent to the ophthalmologist for further examination. The ophthalmologist got in this way a large clientage for consultation. This group soon proved to be most varying. A large number of cases showed no changes in the eye at all, but cases of the type of retinal arteriosclerosis as well as those of the type of retinitis albuminurica were included.

If one looks at the group of arterial hypertension as a unit one can thus distinguish between certain categories:

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1) A large group of this clientage shows neither in the first nor in the consecutive examinations any deviations from the normal state of the fundus.

2 ) A rather large part of the group, however, shows changes in the retinal vessels. They first appear as a light venous stasis and as an irregularity in the diameter of the arteries and in further advanced cases as a general narrowing of the arteries. An increased tortuosity can also be noticed, but it is difficult to draw any conclusions on account of the.considerable in- dividual variations. In this group one meets an increase of the arterial reflex and above all the crossing phenomena. In more advanced 'cases small haemorrhages can be noticed here and there - the whole picture more or less in accordance with the phenomenon earlier called retinal arteriosclerosis.

The pathological-anatomical foundation for this group is remarkably small. The irregularity of the diameter of the vessel is apparently caused by a spasm, just as the general narrowing, at least in the beginning. The crossing phenomena depend in many pronounced cases on a proliferation of the adventitia, but this does not exclude that the symptom can from the beginning have been caused by a mechanical compression.

The clinical course is comparatively benign. These patients are primarily threatened by haemorrhages and thrombosis, especially dangerous if they hit the central nervous system and the heart. As far a~ the eye is concerned a retinal thrombosis is a comparatively frequently occuring complication, most often starting from a vascular crossing and apparently due to the here decreased speed of the flow.

3) In a smaller number of cases there are besides vascular changes of the above mentioned kind - more or less pronounced - also retinal oedemas, exudative spots and haemorrhages. This group is in reality identical with the cases which have earlier been diagnosed as retinitis albuminurica. To this group can also be counted the toxaemia of pregnancy which can lead to irreparable damages, if the toxic condition is not overcome in short time.

The pathological-anatomical foundation for this category is better known than that of the before mentioned. As far as the vessels are concerned one can find areas with a fatty infiltration. One has also found a proliferation of the media but no hyaline degeneration. These vascular changes are, however, remarkably little developed, as for example in comparison with the conditions in the choroid, where in this form of increasing pressure more serious vascular damages with fibrinous degeneration can be observed. In the retinal tissue one can in certain areas find fatty degenerations and also an exudation of fibrin as well as more or less extended haemorrhages.

The prognosis for this group is as before mentioned fairley bad. Most of the cases end upp with uremia within one or a couple of years.

Now I come to the question: What does the physician want to know

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from the ophthalmologist and which symptoms are of special interest? Without entering into any theories I will first point out that the vascular changes in the comparatively mild form have a certain interest for the completion of the medical journal. They can also as in cases with pronounced crossing phenomena give a certain knowledge how long the hypertension has existed showing that the state is not recently developed, but mainly the prognosis is judged more with consideration to the existence of vascular changes in the heart and in the central nervous system than from conclusions drawn from the above mentioned changes in the fundus. These vascular changes in the retina are hardly of so great an importance aa has recently been attributed to them. For the ophthalmologist they are of interest because they show the existence of hypertension. The physician on the other hand cannot get any more important guidance from them.

Entirely different is the question at signs of oedema in the retina, pro- nounced haemorrhages and exudative spots. Here the observations from the 1850-ties are still valid, that the prognosis is very bad. It is now known that the changes in the eye ground exist specially in cases of illness which lead to a rapid reduction of the glomeruli. This explains that these cases may lead to uremia. Earlier than other clinical symptoms these show in many cases the threatening danger, and the importance of recognizing this developing process has augmented with the increased possibilities of treatment which the sympathectomy gives.

With this background - how are the changes in the fundus to be headlined? The earlier nomination of retinitis albuminurica is not adequate as it is not a question of a retinitis, nor is there always albumen. Patients with the retinal changes mentioned are all suffering from hypertension and consequently one now places changes, both in the benign as well as in the malign form under one nomenclature, fundus hypertonicus.

Within the group under this name one has, however, tried to make differentiations and according to a proposal of KEITH & WAGENER they have been divided into four groups. To the first two groups only cases with vascular changes are referred, to the first one of these the more insignificant ones and to the second the more pronounced cases. To the third and fourth group belong cases with retinal hamorrhages and exudations and papilloedema.

Many have adopted this classification but certain objections can be made. Firstly it must be pointed out that the grouping is purely descriptive. The ophthalmologist only describes what he has found and places the cases in one of the groups, the one best corresponding to his observations. Even if the grouping intends to show up the general character of the vascular disease, this method is not well adopted to give a direct answer to the first and foremost question of the physician, whether there are signs of malignity and of which character.

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It is further to be noticed that the particular details in the finding of vascular disease do not always mean the same thing. Thus for instance a case with a general narrowing of the arteries should be classified in group one or two, while in reality the narrow vessels can be the earliest sign of a most malignant case, which GRANSTROM has pointed out with early cases of toxaemia of pregnancy. The claasification can thus become directly misleading.

Conclusively can be said that the KEITH-WAQENER scheme notes a lot of details of a second grade value. It does not lay stress upon the real problem.

With a differentiation under the nomination of fundus hypertonicus must above all be shown whether.the changes are indicating a comparatively mild form of hypertension, fundus hypertunicus simplex, or a serious type, fundus hypertonicus malignus. The interest must first of all be directed to look out for symptonis which show a serious case or an aggravation of a formerly benign process. And one must pay special attention to pronounced arterial contraction and also to the presence of oedema, haemorrhages or exudates.

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