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Hypertension and the Eye

Hypertension and the Eye. John B. Crane, O.D. Clinical Assistant Professor College of Optometry University of Missouri- St. Louis Member, Missouri Diabetes Advisory Board. The Basics. Most people with hypertension never develop vision problems due to their disease

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Hypertension and the Eye

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  1. Hypertension and the Eye John B. Crane, O.D. Clinical Assistant Professor College of Optometry University of Missouri- St. Louis Member, Missouri Diabetes Advisory Board

  2. The Basics • Most people with hypertension never develop vision problems due to their disease • If vision is directly affected by hypertension, usually the patient’s life is at risk (malignant hypertension) • Long term reduced vision due to direct and indirect effects of hypertension is fairly rare • “Hypertensive Retinopathy” refers to the chronic and acute retinal signs that occur in the retina due to hypertension

  3. Hypertensive Retinopathy-What is it? • Findings all stem from changes induced in the retinal microvasculature by hypertension. Similar changes occur elsewhere in the body. • Arteriosclerosis • Chronic abnormal thickening and hardening of medium and large arterial walls resulting in artery straightening & loss of artery elasticity • Arteriolosclerosis • Thickening of the inner wall of small arteries (arterioles) by fatty deposits resulting in obstructed blood flow

  4. RetinalBlood Supply

  5. Retinal Anatomy

  6. Hypertensive Retinopathy-Clinical Findings • Chronic signs: Arterial narrowing (“attenuation”), artery-vein crossing changes with venous constriction and banking, artery “straightening”, arteriolar color changes • Acute signs: • Cotton-wool spots (diastolic usually >110) • Flame hemorrhages • Optic disc edema (BP usually >250/150) • The garden hose analogy

  7. Cotton wool spots & flame hemorrhages

  8. Cotton wool spots, disc edema& macular edema

  9. Indirect Ocular Associations with Hypertension • Hypertensive patients have a higher risk of: • Branch retinal vein occlusion • Ischemic optic neuropathy • Retinal macroaneurysm • Severe diabetic eye complications

  10. Branch retinal vein occlusion with macular edema

  11. Old BRVO & Hypertensive vessel changes

  12. Branch retinal vein occlusion & macular hole

  13. Small macroaneurysm

  14. Large macroaneurysm

  15. Clinical Studies • Those with relatively narrowed arterioles are twice as likely to develop severe hypertension in 5 years as people with relatively wider arterioles (Hypertension: Journal of the American Heart Association) • Suggests that structural microvascular changes, visible in the eye, may precede development of severe hypertension • Therefore, effective treatment for early hypertension may need to specifically target the microcirculation • Also suggests that visible structural changes in the retinal arterioles could be a better measure of long term risk than blood pressure measurements (which can vary significantly)

  16. Clinical Studies • Those who are regular users of aspirin (daily to weekly use) have wider retinal arteriole diameters than nonusers, suggesting that aspirin affects small retinal vessels in a measurable way (ARVO, May 2005) • Narrow vessels are associated with stroke, heart attack, heart failure, and peripheral vascular disease • Unknown whether the changes seen in the eye are also seen in the brain, heart, and other organs • Ongoing research will try to determine how this new knowledge can be applied to help reduce the risk of organ damage related to hypertension

  17. Clinical Cases

  18. 36 yo AAF cc: “blur at all distances” OD>OS HPI: location: OD floater? “blurry spot that moves” OS “one side blurry” duration: x 1 wk timing: “all of the time” severity: severe assoc s/s: +photophobia x 1wk., itch, burn, eyestrain while reading x 1 wk HA: 2 per month x 3 months timing varies, sharp generalized pain at temples, pain rating 8, Excedrin helps

  19. POHx: unremarkable FOHx: unremarkable ROS: +HTN- had baby 3 months previously, hospitalized for 70 days prior to delivery due to BP spikes and BS fluctuations +IDDM x 11 yrs., pt. reports blood sugar kept at 120 mg/dL or lower; ?A1C Meds: Insulin Lisinopril 20mg qd

  20. 36 y.o. AAM • cc: “Blurry vision in left eye” • Entering VA c Rx: OD 20/20-3 OS 20/400

  21. OS

  22. 2 weeks later: • Had CT to r/o CVA, secondary to right-sided weakness, visual disturbance, and incontinence • Found: • “Intraventricular hemorrhage and intraparenchymal hemorrhage including the left basal ganglion and left periventricular white matter areas” • “Left to right shift” • “Edema of the left hemisphere • In other words: The patient stroked out…

  23. 10 days later: • Admitted to neuro-intensive care • Patient found to have “no purposeful movements” upon arrival • Lab history includes toxicity screen positive for cocaine • BP: 198/109 • Assessment: • “Bleed site is likely the left thalamus” • Plan: • “Patient has extremely poor prognosis”

  24. “Pt. nonresponsive to verbal or painful stimuli. No spontaneous heart tones or respirations. Pupils fixed and dilated.” • “Death pronounced at 13:28, family at bedside, chaplain present.”

  25. Questions?

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