Hypertensive Retinopathy

Hypertensive Retinopathy
SYMPTOMS Typically asymptomatic
May report Central vision loss and Metamorphopsia in the presence of cystoid macular edema, Central vision loss and Peripheral vision loss in the presence of optic nerve edema and choroidopathy
SIGNS Typically bilateral
Vessel attenuation, AV nicking (includes Salus sign, Gunn sign, and Bonnet sign), Copper wiring, Silver wiring, Microaneurysms, Dot/blot hemorrhages, Flame hemorrhages, Roth spots, Cotton wool spots, Exudates, Macular edema, Optic nerve edema
Keith-Wagener-Barker Classification
Grade 1: Mild-moderate attenuation (A/V ratio is about ½ to 1), Copper wiring
Grade 2: Moderate-severe attenuation (A/V ratio is less than ½ to 1), AV nicking (Salus sign), Copper wiring
Grade 3: Moderate-severe attenuation (A/V ratio is less than ½ to 1), AV nicking (Salus sign, Bonnet sign, Gunn sign), Copper wiring, Silver wiring, Microaneurysms, Flame hemorrhages, Dot/blot hemorrhages, Cotton wool spots, Roth spots, Exudates (may be in a star like configuration), Cystoid macular edema
Grade 4: All signs found in Grade 3 hypertensive retinopathy and Optic nerve edema
Diastolic blood pressure is usually 110-115mmHg for Grade 3 hypertensive retinopathy and 130-140mmHg for Grade 4 hypertensive retinopathy
Simplified Classification
Mild (Needs to include one or more of the following): Vessel Attenuation, AV nicking (Salus sign, Bonnet sign, Gunn sign), Copper wiring
Moderate (Signs of mild hypertensive retinopathy with one or more of the following): Silver wiring, Microaneurysms, Flame hemorrhages, Dot/blot hemorrhages, Cotton wool spots, Roth spots, Exudates (at this stage, may also see exudates form a star around the macula as these exudates are found in Henle layer), Cystoid macular edema
Malignant (Signs of mild and moderate hypertensive retinopathy and the following): Optic nerve edema
Diastolic blood pressure is typically greater than 90 and less than 110mmHg for mild hypertensive retinopathy, greater than or equal to 110 and less than 120mmHg for moderate hypertensive retinopathy, and greater than or equal to 120mmHg for malignant hypertension
WORK-UP Pupils, EOMs, Full eye exam with dilated retinal exam, OCT analysis of the macula (signs of cystoid macular edema are best seen with an OCT), OCT analysis of the optic nerve, OCT-Angiography, Fluorescein Angiography, Indocyanine Green Angiography, Fundus Autofluorescence, Fundus photos, Infrared photos, Watzke-Allen test, Macular photostress test, Amsler grid
TREATMENT Give take home Amsler grid in order to monitor for change (especially if patient has Grade 3 to 4 hypertensive retinopathy or Moderate to Malignant hypertensive retinopathy)
Patient needs to follow up with their primary care provider and control blood sugar, blood pressure, and cholesterol (the key to treating hypertensive retinopathy is to keep blood pressure in control)
Grade 1 to 2 or Mild hypertensive retinopathy: Non-urgent referral to their PCP
Grade 3 or Moderate hypertensive retinopathy: Urgent referral to their PCP
Grade 4 or Malignant hypertensive retinopathy: Immediate referral to their PCP or ER
Refer to a retinal specialist ASAP if the patient presents with cystoid macular edema associated with hypertensive retinopathy
FOLLOW-UP Grade 1 to 2 or Mild hypertensive retinopathy: Patient should be seen back in 9-12 months
Grade 3 or Moderate hypertensive retinopathy: Patient should be seen back in 4-6 months
Grade 4 or Malignant hypertensive retinopathy: Patient should be seen back in 1-2 months
If macula is stable following treatment by retinal specialist, patient should be seen back in 3-4 months
ADDITIONAL LAB | TESTS The patient needs to follow-up with their PCP for additional testing if not already done which includes the following: Blood pressure, Fasting blood sugar, HbA1c, Lipid panel, CBC with differential, Renal function testing
ETIOLOGY Vasoconstrictive phase: High blood pressure causes vasoconstriction and subsequent narrowing of the retinal arteries and arterioles
Sclerotic phase: High blood pressure will cause arteriosclerosis of the retinal arteries, arterioles, and capillaries with subsequent thickening, hardening, and damage to the vessel wall
Exudative phase: Damage to the retinal arteries, arterioles, and capillaries will cause breakdown of the inner-blood retina barrier which will cause leakage and hypoxia
DIFFERENTIAL DX Diabetic retinopathy, Anemia retinopathy, Sickle cell retinopathy, HIV retinopathy, Leukemia retinopathy
NOTES The highest predictor of developing severe hypertensive retinopathy is kidney disease
Flame hemorrhages are more common to be seen in hypertensive retinopathy compared to dot/blot hemorrhages
Cotton wool spots typically outnumber retinal hemorrhages
Signs of hypertensive retinopathy are reversible with treatment and control of blood pressure
Young patients with uncontrolled hypertension can also develop Hypertensive Choroidopathy which can lead to Elschnig spots, Siegrist streaks, RPE detachments, Localized sensory retinal detachments, Choroidal nonperfusion
Hypertensive Retinopathy: Fundus photo demonstrating Grade 2 or Mild hypertensive retinopathy https://en.wikipedia.org/wiki/Hypertensive_retinopathy
Posted in Ocular Conditions, Retina-Vascular