HYPERTENSIVE

RETINOPATHY
By : Dr. Naveen Nischal G
Introduction

■ Hypertension is the leading risk factor for cardiovascular disease (CVD) and
mortality worldwide
■ Causes :
1. Hypertensive Retinopathy
2. Hypertensive Choroidopathy
3. Hypertensive Optic Neuropathy.
Risk Factor

■ Hypertension is also a major risk factor for many other eye diseases like
1. Development and progression of diabetic retinopathy
2. Retinal vein occlusion
3. Retinal arterial macroaneurysm
4. Age-related macular degeneration
5. Glaucoma.
Definition and Classification

■ Retinopathy is the most common manifestation of hypertension which develops due

to acute and/or chronic elevations in blood pressure.
■ Broadly divided into various phases :
a. Vasoconstrictive Phase
b. Sclerotic Phase
c. Exudative Phase
d. Malignant Hypertension
■ Elevated blood pressure does not fully explain all the pathophysiological
mechanisms of hypertensive retinopathy.
■ Other processes involved in the pathogenesis of hypertensive retinopathy signs
include inflammation, endothelial dysfunction, abnormal angiogenesis, and
oxidative stress.
Classification

■ Keith Wagner Baker system :

a. Grade 1 : Mild generalized retinal arteriolar narrowing.
b. Grade 2 : Focal arteriolar narrowing and arteriovenous nipping. A ‘copper wiring’
opacified appearance of arteriolar walls may be seen.
c. Grade 3 : Grade 2 plus retinal haemorrhages, exudates and cotton wool spots.
d. Grade 4 : Severe grade 3 plus optic disc swelling; this is a marker of malignant
hypertension.
Newer Classification

1. None: no detectable signs.

2. Mild: Generalized arteriolar narrowing, focal arteriolar narrowing, arteriovenous
nicking, arteriolar wall opacification (silver or copper wiring), or a combination of
these signs.
3. Moderate: Hemorrhages (blot, dot, or flame-shaped), microaneurysms, cotton-wool
spots, hard exudates, or a combination of these signs.
4. Malignant: Signs of moderate retinopathy in combination with optic disc swelling, in
the presence of severely elevated blood pressure.
■ Presence of Hypertensive retinopathy, with Left Ventricular Hypertrophy and Renal
Impairment, is an indicator of target organ damage.
■ Its presence should be an indication for a more aggressive approach in managing
these hypertensive patients.
Epidemiology

■ Age
■ Gender – Men more than Women
■ Ethnicity – Chinese more than whites
■ Blood Pressure Levels
■ Generalized retinal arteriolar narrowing and arteriolar nicking – Markers of chronic
hypertension.
■ Focal arteriolar narrowing, retinal hemorrhages, microaneurysms and cotton-wools
spots – Mirror short term blood pressure changes.
Hypertensive Choroidopathy

■ Mechanism of hypertensive choroidopathy - Choroidal ischemia which has effects

on the retinal pigment epithelium and retina.
■ The choroidal vessels may undergo fibrinoid necrosis at the level of the choroidal
capillaries in the presence of elevated blood pressure.
■ Elschnig spots - round, deep, and gray-yellow patches at the level of the retinal
pigment epithelium
■ Siegrist streaks - inear hyperpigmented streaks along choroidal arteries
■ In severe cases, there may also be serous retinal detachment which can lead to
vision loss.
Hypertensive Optic Neuropathy

■ Bilateral optic disc swelling or papilloedema is commonly caused by accelerated or

malignant hypertension, representing the “malignant hypertensive retinopathy”
stage in the above classification.
■ Why optic disc swelling occurs is still uncertain.
■ Ischemia, Raised Intracranial pressure, Hypertensive encephalopathy all are
possible mechanisms.
■ Need urgent anti hypertensive management.