Update on Hypertensive Retinopathy

Dkt. Muchai Gachago

Introduction

• First described in the late 1800s• Used to predict risk of stroke, cardiovascular

disease, and even mortalityEpidemiology• HR in 3% to 14% of nondiabetic adults age

≥40.• 10 year cumulative incidence is 16%.

PATHOGENESIS AND PRESENTATION

• spectrum of “retinal vascular signs” caused by elevated blood pressure.

• Autoregulation of the vasculature → breakdown of autoregulation pathways and atherosclerosis

Signs

Signs

Signs

Signs

Signs

Long-term Consequences

• Arteriolosclerosis - irreversible→opacification, compression of venules.

• BRB disruption→“exudative” stage

• “Malignant” stage → optic disc and macular oedema due to raised intracranial pressure.

Keith–Wagener–Barker ClassificationGrade Features

1 Mild generalized retinal arteriolar narrowing

2 Definite focal narrowing and arteriovenous nipping

3 Signs of grade 2 retinopathy plus retinal hemorrhages, exudates, and cotton wool spots

4 Severe grade 3 retinopathy plus papilloedema

-Poor reliability and reproducibility-Grades do not correlate with severity of hypertension-Not sequential in nature-Grades do not correlate with prognosis, cardiovascular events, and mortality.

Simplified ClassificationGrade FeaturesMild( retinal arteriolar signs)

Generalized arteriolar narrowing, focal arteriolar narrowing, arteriovenous nicking, opacity (“copper wiring”) of arteriolar wall, or a combination of these signs

Moderate(retinopathy-like lesions)

Retinal hemorrhages (blot-shaped, dot-shaped, or fiame-shaped), microaneurysms, cotton wool spots, hard exudates, or a combination of these signs

Malignant Signs of moderate retinopathy plus optic disk swelling

-Good reliability and reproducibility.-Predicted the long-term risk of stroke. -Ease of use -Appropriate stratification of cardiovascular risk disease.

Recent Observations• ↑blood pressure →higher frequency of retinopathy signs

• Long-term hypertension → Generalized retinal arteriolar narrowing & AVN. Assoc with ↑BP control in past 10yrs

• Focal arteriolar narrowing and retinopathy lesions related only to concurrently measured blood pressure.

• Assoc between BP and retinal microvascular signs ↓with age

• Smaller retinal arteriolar and larger venular calibers precede clinical stages of hypertension and predict the risk of hypertension in initially normotensive individuals.

RELATIONSHIP WITH TARGET ORGAN DAMAGE

Atherosclerosis Risk in Communities (ARIC) study, subjects with HR:

• ↑ risk of developing incident stroke• Cognitive decline• Cerebral white matter lesions• Cerebral atrophy• Predicted the long-term risk of stroke• Incident stroke (19.3% vs 4.3%) and incident

cerebral infarction (15.5% vs 3.6%)

Kidney and Heart Disease

• ↑Chronic kidney disease (CKD) & microalbuminuria

• Stroke * 7• Heart attack * 4• Coronary artery disease * 3• Peripheral artery disease * 2

CLINICAL MANAGEMENTRetinopathy Grade Systemic Associations Management

MildWeak associations with stroke, coronary heart disease and cardiovascular mortality

Routine care Closer monitoring of vascular risk

Moderate

Strong association with stroke, congestive heart failure, renal dysfunction, and cardiovascular mortality

Exclude diabetes Closer monitoring of vascular risk Possible indication for hypertension treatment and other risk factors

Malignant Associated with mortality Urgent hypertension treatment

Hypertensive Choroidopathy

Elschnig Spots: Focal choroidal infarcts

Siegrist Streaks: Fibrinoid necrosis

Exudative RD

Complications

Complications

Complications

Further Reading

• Retinal Physician, Volume: 10 , Issue: November 2013, page(s): 43 – 54...Review Article Reviewing 96 papers on Hypertension and HR.