HYPERTENSIVE

RETINOPATHY
 DEFINITION
 the ophthalmic findings of end-organ damage secondary to
systemic arterial hypertension(defined as systolic greater
than 140 mmHg and diastolic greater than 90 mmHg)
 Including optic neuropathy, choroidopathy, and
retinopathy
 2 form : - Chronic Hypertensive Retinopathy
- Malignant Acute Hypertensive
Retinopathy
EPIDEMIOLOGY
 Second most common retinal vascular disease
 incidence confounded by other retinal vascular
diseases, such as diabetes
 Prevalence of Hypertension in Thailand = 22% in
men and 21.4% in women
 Incidence of hypertensive retinopathy was about
15%(Beaver Dam Eye Study)
 Systemic Hypertension 10-15% in UK(> 40 aged
group)
 Malignant Hypertension(200/140mmHg) 1% of
Hypertension
RISK FACTORS: ESSENTIAL HYPERTENSION
 Ethnic background:Afro-Caribbeans
 Age > 40

 Family History

 Medications

 Obesity

 Smoking/Tobacco use

 Stress

 Alcohol Consumption

 Lack of Exercise

 High salt diet

SEVERITY
 arteriosclerotic hypertensive retinopathy is the
duration of elevated blood pressure
 malignant hypertension is the amount of blood
pressure elevation over normal
GENERAL PATHOLOGY
 In ocular arterioles: elevated luminal BP 
vasoconstriction (to reduce flow) endothelial
damage  smooth muscle degeneration 
stretching, break, and leakage of plasma into wall
 mural thickening + luminal narrowing 
“fibrinous necrosis”

“4 stages of Keith Wagener Barker (KWB) Grades”

PATHOPHYSIOLOGY
As a result of “fibrinous necrosis”
 necrotic vessels bleed into nerve fiber layer
(flame shaped hemorrhage)
 necrotic vessels bleed into inner retina (dot blot
hemorrhage)
 Ischemia to the nerve fibers  decreased
axoplasmic flow  nerve swelling  fluffy
opacification (cotton wool spots)
 lipid accumulation surrounding areas of
hemorrhage (exudates)
PATHOPHYSIOLOGY
Optic disc arterioles :
 Ischemia  optic nerve swelling  blurred disc
margins
 leakage  hemorrhage  disc edema
KEITH WAGENER BARKER (KWB) GRADES
 Grade 1
 Generalised arteriolar constriction - seen as
`silver wiring` and vascular tortuosities.
 Grade 2
 As grade 1 + irregularly located, tight
constrictions - Known as `(AV) nicking` or `AV
nipping`
 Grade 3
 As grade 2 + with cotton wool spots and flame-
hemorrhages
 Grade 4
 As above but with swelling of the optic disk
(papilledema)
CRITERIA DIAGNOSIS
 Made by thorough history of the patient,
ophthalmoscopy (direct or indirect) and also
physical examination
 History
 Decrease of patient vision
 Occipital headache
 High blood pressure
 Possible history of systemic hypertension
CRITERIA DIAGNOSIS
 Physical examination
 Opthalmoscopy
 Non Malignant Retinopathy
 Focal arteriole narrowing

 Arterio-venous crossing changes

 Arterioles color changes

 Vessel sclerosis
ARTERIO VENOUS CROSSING CHANGE
 Venous deflection (Salus’ sign)
 Localized venous narrowing
(nipping,Gunn’s sign)
 Right-angled crossing

by venous deflection
 Venous distal

banking
(Bonnet’s sign)
CRITERIA DIAGNOSIS
 Malignant Hypertensive Retinopathy
 Show changes in arteriovenous crossings

 Cotton-wool spot

 Copper and Silver wire appearance of narrowed

arterioles
 Nicking of veins where arteries cross them(arteriovenous

nicking)
 Hard exudates“lipids deposites”

 “Macularstar”

 Flame shape hemorrhage

 Retinal edema

 Swelling of the optic nerve

 Aterial microaneurysms

 Arteriolar macroaneurysms

 Tortuosity in retinal arterioles

FOCAL NARROWING OF RETINAL
ARTERIOLES-COPPER AND SILVER WIRING
Early malignant Advanced
malignant
CRITERIA DIAGNOSIS
 Sphygmomanometry
 Blood pressure measurement is required to make a positive
diagnosis in the absence of malignant retinopathy changes

 Arteriole narrowing
Young patients : Older patients :
autoregulation causes arterosclerosis and
uniform narrowing of autoregulation causes
retinal arterioles focal narrowing of retinal
arterioles
 Assess the arterio-venous calibre ratio as a percentage
o Adjacent arteries and vein

o Equivalent numbers of bifurcation

o Between 1 and 3 DD from optic disc

CLASSIFICATION
 Keith-Wagener-Barker classification
Grad Description
e
Grade 1 Slight narrowing, sclerosis, and tortuosity of the retinal arterioles; mild,
asymptomatic hypertension

Grade 2 Definite narrowing, focal constriction, sclerosis, and AV nicking; blood pressure is
higher and sustained; few, if any, symptoms referable to blood pressure

Grade 3 Retinopathy (cotton-wool patches, arteriolosclerosis, hemorrhages); blood pressure is

higher and more sustained; headaches, vertigo, and nervousness; mild impairment
of cardiac, cerebral, and renal function

Grade 4 Neuroretinal edema, including papilledema; Siegrist streaks, Elschnig spots; blood
pressure persistently elevated; headaches, asthenia, loss of weight, dyspnea, and
visual disturbances; impairment of cardiac, cerebral, and renal function
CLASSIFICATION
 Scheie classification
Staging under this system is as follows:
Stage 0 - Diagnosis of hypertension but no visible retinal abnormalities

Stage 1 - Diffuse arteriolar narrowing; no focal constriction

Stage 2 - More pronounced arteriolar narrowing with focal constriction
Stage 3 - Focal and diffuse narrowing, with retinal hemorrhage
StageScheie
The 4 - Retinal edema, hard
classification exudates,
also gradesoptic
the disc
lightedema
reflex changes from
arteriolosclerotic changes, as follows :
Grade 0 - Normal
Grade 1 - Broadening of light reflex with minimal arteriolovenous compression
Grade 2 - Light reflex changes and crossing changes more prominent
Grade 3 - Copper-wire appearance; more prominent arteriolovenous
compression
Grade 4 - Silver-wire appearance; severe arteriolovenous crossing changes
CLASSIFICATION

Modified Scheie classification

Grade 0 - No changes

Grade 1 - Barely detectable arterial narrowing

Grade 2 - Obvious arterial narrowing with focal irregularities

Grade 3 - Grade 2 plus retinal hemorrhages and/or exudates

Grade 4 - Grade 3 plus disc swelling

MANAGEMENT
•Appropiate treatment of the underlying hypertension
•If the patient is previously undiagnosed the patient needs
referral to the GP for assessment
• A grade I or grade II hypertensive retinopathy
- Non-urgent referral
• A grade III hypertensive retinopathy
- More urgent referral to the GP
• A grade IV hypertensive retinopathy
- Needs immediate referral to Ophthalmologist
HYPERTENSIVE RETINOPATHY –
ASSOCIATED CONDITIONS
 Retinal vein occlusion
 Retinal arterial occlusion

 Retinal arterial macroaneurysm

 Anterior ischemic optic neuropathy

 Ocular motor nerve palsy

 Uncontrolled hypertension may adversely

affect diabetic retinopathy

CLINICAL PEARLS