FA conference
Hypertensive RetinopathyAmir R. Hajrasouliha, M.D.
University of LouisvilleDepartment of Ophthalmology and Visual Sciences
Thursday, May 1st, 2014
Patient Presentation CC: Decreased vision OD x 3 weeks
HPI: 53 y/o white female presented with decreased vision OD. She c/o gradual vision loss for past 3 weeks in the right eye. She denies any trauma or pain in the eye.
Patient Presentation
PMH: Chronic kidney failure on dialysis x4 months, HTN
POH: None
Meds: Clonidine, Crestor, Norvasc
Allergies: Ampicillin
Vital signs: BP: 160/90; HR: 78; T: 37
Exam
BCVA Tp EOM FULL OU
APD 2+ OD
SLE: OD OSExt WNL WNLC/S CLEAR CLEARK WNL WNLAC FORMED FORMEDI/L 1+ NS 1+ NS
HM +1.75 +1.00 x105 16
1720/40-1 +1.00 +0.75 x95
Color fundus photo
Optic nerve edema OD>OS with surrounding intraretinal hemorrhages
Assessment
53 y/o WF with hypertensive retinopathy and choroidopathy OD>OS
-Differential diagnosisCRVODiabetic retinopathy
Plan – Avastin OD
Hypertensive retinopathy Retinopathy is the most common manifestation
of hypertension which develops due to acute and/or chronic elevations in blood pressure. Vasoconstrictive phase- clinically as generalized
arterial narrowing. Sclerotic phase- with persistent elevated BP causing
intimal thickening and copper wiring Exudative phase- chronic sustained BP elevation
with disrupted blood-retinal barrier and cotton-wool spots
Malignant hypertensive phase – optic disk swelling
In cohort of 49 treatment-naïve individual the Wall to Lumen Ratio was found positively correlated to mean blood pressure.
In cohort of 49 treatment-naïve individual the Wall to Lumen Ratio was found positively correlated to mean blood pressure.
Hypertensive retinopathy classification
Traditionally, the Keith–Wagener–Baker system classifies patients with hypertension into four groups of increasing severity. 1. None 2. Mild: Generalized/Focal arteriolar narrowing 3. Moderate: Hemorrhages (blot, dot, or flame-
shaped), microaneurysms, cotton-wool spots, hard exudates
Hypertensive retinopathy classification
Traditionally, the Keith–Wagener–Baker system classifies patients with hypertension into four groups of increasing severity. 1. None 2. Mild: Generalized/Focal arteriolar narrowing 3. Moderate: Hemorrhages (blot, dot, or flame-
shaped), microaneurysms, cotton-wool spots, hard exudates
4. Malignant: Signs of moderate retinopathy in combination with optic disc swelling
Hypertensive choroidopathy
Like the retinal vessels, the choroidal vessels may also undergo fibrinoid necrosis at the level of the choroidal capillaries in the presence of elevated blood pressure, leading to hypertensive choroidopathy signs that include: Elschnig spots (round, deep, and gray-yellow patches at the
level of the retinal pigment epithelium) and Siegrist streaks (linear hyperpigmented streaks along
choroidal arteries).
In severe cases, there may also be serous retinal detachment which can lead to vision loss.
Elschnig spots
Elschnig spots (arrow) are gray-yellow patches at the level of the retinal pigment epithelium
Siegrist streaks
Siegrist streaks (arrows) are linear hyper-pigmented streaks over choroidal arteries, and they denote ischemia of the large choroidal vessels.
Presentation
10 mths f/u with BP control
3 mths post
Avastin
Kim EY, Lew HM, Song JH. J Ocul Pharmacol Ther. 2012 Jun;28(3):318-22
Thank You