The retina is one of the "target organs" that are damaged by sustained hypertension. Subjected to excessively high blood pressure over prolonged time, the small blood vessels that involve the eye are damaged, thickening, bulging and leaking.

Early signs of retinopathy correlate less well with mortality and morbidity that used to be thought, but signs of accelerated or "malignant" hypertension indicate severe illness.

Symptoms

Most patients with hypertensive retinopathy present without visual symptoms, however, some may report decreased vision or headaches.

Signs

Signs of damage to the retina caused by hypertension include:

Arteriosclerotic changes
- Arteriolar narrowing that is almost always bilateral
  - Grade I - 3/4 normal caliber
  - Grade II - 1/2 normal caliber
  - Grade III - 1/3 normal caliber
  - Grade IV - thread-like or invisible
- Arterio-venous crossing changes (aka "AV nicking) with venous constriction and banking
- Arteriolar color changes
  - Copper wire arterioles are those arterioles in which the central light reflex occupies most of the width.
  - Silver wire arterioles are those in which the central light reflex occupies all of the width of the arteriole.
- Vessel sclerosis
Ischemic changes (e.g. "cotton wool spots")
Hemorrhages, often flame shaped.
Edema
- Ring of exudates around the retina called a "macular star"
Papilledema, or optic disc edema, in patients with malignant hypertension
Visual acuity loss, typically due to macular involvement

Diagnosis

Fluorescein angiography
Ophthalmoscopy
Sphygmomanometry

Treatment and management

A major aim of treatment is to prevent, limit, or reverse such target organ damage by lowering the patient's high blood pressure. The eye is an organ where damage is easily visible at an early stage, so regular eye examinations are important.

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Diabetic retinopathy
From Optometric Management, 10/1/03

Demographics

* Age range at onset: Variable, depending on duration of diabetes and glycemic control

* Gender trends: Women slightly more susceptible

* Racial trends: African-American and Hispanic patients at increased risk

* Family history: Strong association

* Refractive error trends: None

* Associated medical conditions: Diabetes of long duration (>10 years), obesity, hypertension, cardiovascular disease, nephropathy, neuropathy

* Associated ocular conditions: Cataract, rubeosis iridis (neovascularization of the iris that may cause acute angle-closure glaucoma), chronic open-angle glaucoma.

Symptoms

* Patients may remain asymptomatic far beyond optimal treatment stage.

* Patients may experience insidious vision loss.

Differential diagnosis

* Hypertensive retinopathy: Cotton wool spots, hard exudates and hemorrhages may be seen; however, severe disc edema is a prominent feature not seen in diabetic retinopathy. Neovascularization is not typically a feature of hypertensive retinopathy.

* CMV retinopathy: Hemorrhage and cotton wool spots may be seen along the arterial arcades; however, there is little neovascularization. Medical history may include high-risk sexual behavior, intravenous (I.V.) drug abuse or previous blood transfusions.

* Sickle cell retinopathy: This may manifest as peripheral retinal neovascularization; however, vascular tortuosity, hemorrhage and hard exudates are not seen. The patient may have a family or personal history of sickle cell crisis.

Manifestations

Mild to Moderate Nonproliferative Diabetic Retinopathy (NPDR)

The initial stage of diabetic retinopathy is the result of capillary leakage and occlusion. Earlystage findings include microaneurysms (pinpoint arterial dilations seen on magnification), hard exudates (yellow lipid deposits that may threaten central vision if located in the macula) and macular edema (gray areas of retinal thickening). Up to 15% of diabetic patients have macular edema.

Management: Assess the intraocular pressure (IOP) and the optic discs for evidence of glaucoma. Assess the lenses for cataracts. Annual dilated exams and retinal photography by an experienced examiner are recommended to monitor disease progress. Fluorescein angiography may be necessary to detect leaking retinal microaneurysms for treatment with focal photocoagulation. Focal and panretinal photocoagulation may increase the visual angle and prevent loss of central and color vision. It is crucial to stress the need for tight glycemic control and careful follow-up with the primary care physician.

Prognosis: Clinically significant macular edema (edema in close proximity to the fovea) is the most common cause of vision loss in this population.

Severe NPDR

Some patients may go on to develop severe NPDR marked by vascular tortuosity, intraretinal microvascular abnormalities, hemorrhage, venous beading and cotton wool spots (white, feathery areas due to infarction of the nerve fiber layer).

Management: Assess the TOP and optic discs for evidence of glaucoma. Frequent dilated exams with retinal photography by an experienced examiner are recommended to monitor disease progress. Panretinal photocoagulation may benefit patients at this stage by destroying ischemic retina and preventing the onset of proliferative disease. It is crucial to stress the need for tight glycemic control and careful follow-up with the patient's primary care physician.

Prognosis: 40% of patients with severe NPDR will develop PDR within 1 year.

Proliferative Diabetic Retinopathy (PDR)

Neovascularization of the disc and retina eventually may occur in response to the prolonged retinal ischemia of NPDR. Hemorrhage with eventual fibrosis and traction retinal detachment may occur. This type of disease may lead to profound vision loss.

Management: Assess the IOP and optic discs for evidence of glaucoma. Assess the iris for evidence of rubeosis. Frequent dilated exams with retinal photography by an experienced examiner are recommended to monitor disease progress. Panretinal photocoagulation is recommended to prevent progression of neovascularization and hemorrhage. It is crucial to stress the need for tight glycemic control and careful follow-up with the patient's primary care physician.

Prognosis: Untreated, this type of retinopathy may lead to profound vision loss. Panretinal treatment in high-risk proliferative retinopathy may result in a 50% decrease in severe vision loss.

Return to Hypertensive retinopathy

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