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