Transcript Hypertensive Retinopathy

HYPERTENSIVE
RETINOPATHY
DR AJAY DUDANI
DR YASHESH MANIAR
-- MANY CAUSES
-- MAINLY ESSENTIAL HYPERTENSION
SYSTEMIC HYPERTENSION
(JNCV 5TH)
STATE OF PERSISTENT ELEVATED BLOOD
PRESSURE ABOVE 140/90 mmHg.
5TH JOINT NATIONAL COMMITTEE CLASSIFICATION
OF BLOOD PRESSURE
CATEGORY
SYSTOLIC BP
DIASTOLIC BP
(mmHg)
(mmHg)
NORMAL
<130
<85
HIGH NORMAL
130-139
85-89
STAGE 1 (MILD)
140-159
90-99
STAGE 2 (MOD.)
160-179
100-109
STAGE 3 (SEVERE) 180-209
110-119
STAGE 4(V. SEVERE) >210
>120
PATHOPHYSIOLOGICAL CHANGES IN HYPERTENSIVE OCULAR
DISEASE
1. HYPERTENSIVE CHOROIDOPATHY
2. HYPERTENSIVE RETINOPATHY
-- VASOCONSTRICTIVE PHASE
-- SCLEROTIC PHASE
-- EXUDATIVE PHASE
-- COMPLICATIONS OF THE SCLEROTIC PHASE
3. HYPERTENSIVE OPTIC NEUROPATHY
-- OPTIC DISC EDEMA
-- OPTIC ATROPHY
-- ISCHEMIC OPTIC NEUROPATHY
OCULAR HYPERTENSION
ARTERIOSCLEROSIS
GRADE 0
NORMAL
GRADE 1
INCREASED LIGHT REFLEX,
WITH MILD ARTERIOVENOUS
CROSSING DEFECTS
GRADE 2
COPPER WIRE APPEARANCE
GRADE 3
SILVER WIRE APPEARANCE,
WITH MARKED ARTERIO
VENOUS CROSSING DEFECTS
GRADE 4
FIBROUS CORD
Grading of arteriolosclerosis
OCULAR HYPERTENSION
ARTERIOLES
A-V RATIO
FOCAL SPASM
GRADE 0
3:4
1:1
GRADE 1
1:2
1:1
GRADE 2
1:3
2:3
GRADE 3
1:4
1:3 +/- C W SPOT
GRADE 4
FIBROUS CORD NO DISTAL FLOW +/-ELS SPOT
HYPERTENSIVE RETINOPATHY
HEMORRHAGE
EXUDATE
DISC EDEMA
GRADE 0
-
-
-
GRADE 1
-
-
-
GRADE 2
-
-
-
GRADE 3
+
+
-
GRADE 4
+
+
+
GRADE 1 HTR



GENERALIZED
ARTERIOLAR
ATTENUATION
BROADENING OF
ARTERIOLAR LIGHT
REFLEX
CONCEALMENT OF
VEIN AT A-V
CROSSINGS
GRADE 2 HTR
SEVERE
GENERALIZED AND
FOCAL ARTERIOLAR
CONSTRICTION
 A-V CROSSING
CHANGES (SALUS
SIGN)

GRADE 3 HTR





Copper wiring of arterioles
Venous banking distal to A-V
crossing (bonnet’s sn)
Venous tapering on either
side of crossing (gunn’s sn)
Right angle deflection of
veins.
Flame shaped hemorrhages
cotton wool spots, hard
exudates.
GRADE 4 HTR

All changes of grade
3

Silver wiring of
arterioles

Disc edema
Ocular associations of
hypertension
Retinal vein occlusion
• CRVO (Central Retinal Vein Occlusion)
• HRVO (Hemi Retinal Vein Occlusion)
• BRVO (Branch Retinal Vein Occlusion)
Constitutes 69.5 % of all RVO cases
CRVO ...
Classic Appearance
Mildest Form
CRVO
NON ISCHAEMIC
ISCHAEMIC
62/F
PR No 17474
CRVO
IVTA
(elsewhere)
62/F PR No 17474 CRVO (S/P IVTA)
3 weeks
20/500
Baseline
20/500
2nd IVTA
Avasti
n
2nd Avastin
3 months
20/200
5 months
20/400
8 months
CRVO
Hayreh et al –
Non – Ischaemic : Due to simple occlusion of
retinal venous system
 Ischaemic : Due to combined occlusion
of
the arterial & venous circulation

Green et al –
Thrombus formation in the region of lamina
cribrosa is the primary event
CRVO
Complications / Sequelae ...

Macular oedema
Haemorrhage

Ischaemia stimulates neovascularization in







Optic disc
Retina
Angle
Iris - Rubeosis may cause Neovascular Glaucoma
Rhegmatogenous RD
Vascular complications


Microaneurysyms
Optociliary vessels – collaterals between retinal & ciliary
vessels
Cilioretinal artery occlusion
Combined with CRVO
Cilioretinal artery occlusion
Combined with
anterior ischaemic
optic neuropathy
HRVO ...
HRVO ...
Superior & Inferior vein do not merge into
Central Vein before entering into lamina
cribrosa
 Like CRVO, only superior or inferior half
involved
 Types

-

2/3rd :
1/3rd :
Venous stasis
Haemorrhagic
Rest Rx or management same as CRVO
BRVO ...
45/M PR No 17422 BRVO
45/M PR No 17422 BRVO
Baseline 20/500
3 weeks
20/500
6 weeks/8 m 20/80
STT
Avastin
BRVO
BRVO ...
Portion of retina involved
 Mostly temporal

- 62% Superotemporal
- 38% Inferotemporal
Nasal – uncommon & asymptomatic
 Occurs
exclusively
at
arterial
overcrossing at AV intersection by a
thrombus

Investigations in RVO ...

Hb/CBC/ESR/Platelet count

BSL – Fasting/PP

BP

Sr. Lipid Profile

IOP Measurement

FFA

ANA/Anti-ds DNA

VDRL/FTA-Abs

LE Cell
In Young ...

Protein C levels

Protein S levels

Platelet Analysis

Sr. & Urine for Homocysteine levels
Others ...

Hb Electrophoresis

PT / PTT

Anti-Phospholipid antibody

Complete Cardiovascular evaluation
Traditional Rx Options ...

To treat the associated systemic diseases
(Medical Rx)

To treat the ocular complications
(Laser or Sx)
- CRVO Study Group
- BRVO Study Group
Ocular associations of hypertension
Retinal artery macroaneurysm
Ocular associations of hypertension
Anterior ischaemic optic neuropathy
Ocular associations of hypertension
Ocular motor nerve palsies