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HYPERTENSIVE RETINOPATHY

Explore the pathophysiological changes, grading, and complications of hypertensive retinopathy caused mainly by essential hypertension. Learn about ocular associations, retinal vein occlusion, and management options. Ocular manifestations of hypertension and its correlation with various eye conditions are discussed in detail.

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HYPERTENSIVE RETINOPATHY

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  1. HYPERTENSIVE RETINOPATHY DR AJAY DUDANI DR YASHESH MANIAR

  2. -- MANY CAUSES -- MAINLY ESSENTIAL HYPERTENSION

  3. SYSTEMIC HYPERTENSION (JNCV 5TH) STATE OF PERSISTENT ELEVATED BLOOD PRESSURE ABOVE 140/90 mmHg.

  4. 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

  5. PATHOPHYSIOLOGICAL CHANGES IN HYPERTENSIVE OCULAR DISEASE • HYPERTENSIVE CHOROIDOPATHY • 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

  6. 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

  7. Grading of arteriolosclerosis

  8. 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

  9. HYPERTENSIVE RETINOPATHY HEMORRHAGE EXUDATE DISC EDEMA GRADE 0 - - - GRADE 1 - - - GRADE 2 - - - GRADE 3 + + - GRADE 4 + + +

  10. GRADE 1 HTR • GENERALIZED ARTERIOLAR ATTENUATION • BROADENING OF ARTERIOLAR LIGHT REFLEX • CONCEALMENT OF VEIN AT A-V CROSSINGS

  11. GRADE 2 HTR • SEVERE GENERALIZED AND FOCAL ARTERIOLAR CONSTRICTION • A-V CROSSING CHANGES (SALUS SIGN)

  12. 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.

  13. GRADE 4 HTR • All changes of grade 3 • Silver wiring of arterioles • Disc edema

  14. 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

  15. CRVO ... Classic Appearance Mildest Form

  16. CRVO NON ISCHAEMIC ISCHAEMIC

  17. 62/F PR No 17474 CRVO IVTA (elsewhere)

  18. 62/F PR No 17474 CRVO (S/P IVTA) 3 weeks 20/500 Baseline 20/500 2nd IVTA Avastin 2nd Avastin 3 months 20/200 5 months 20/400 8 months 20/100

  19. 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

  20. 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

  21. Cilioretinal artery occlusion Combined with CRVO

  22. Cilioretinal artery occlusion Combined with anterior ischaemic optic neuropathy

  23. HRVO ...

  24. 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 : Venous stasis • 1/3rd : Haemorrhagic • Rest Rx or management same as CRVO

  25. BRVO ...

  26. 45/M PR No 17422 BRVO

  27. 45/M PR No 17422 BRVO Baseline 20/500 STT 3 weeks 20/500 Avastin 6 weeks/8 m 20/80

  28. BRVO

  29. 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

  30. Hb/CBC/ESR/Platelet count BSL – Fasting/PP BP Sr. Lipid Profile IOP Measurement FFA ANA/Anti-ds DNA VDRL/FTA-Abs LE Cell Investigations in RVO ...

  31. Protein C levels Protein S levels Platelet Analysis Sr. & Urine for Homocysteine levels In Young ...

  32. Hb Electrophoresis PT / PTT Anti-Phospholipid antibody Complete Cardiovascular evaluation Others ...

  33. 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

  34. Ocular associations of hypertension Retinal artery macroaneurysm

  35. Ocular associations of hypertension Anterior ischaemic optic neuropathy

  36. Ocular associations of hypertension Ocular motor nerve palsies

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