Hypertensive Retinopathy

- Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to both transient & persistent microvascular damage from elevated BP.
- The primary response of the retinal arterioles to systemic hypertension is narrowing (vasoconstriction).
- The
he degree of narrowing is dependent on the amount of pre pre-existing replacement fibrosis (involutional sclerosis).
• For this reason, hypertensive narrowing is seen in its pure form only in young in individuals.
dividuals. In older patients, rigidity of retinal arterioles due to involutional
sclerosis prevents the same degree of narrowing seen in young individuals.
- In sustained hypertension the inner blood–retinal
retinal barrier is disrupted in localized areas, with increased vascular permeability.
Signs
1 Arteriolar narrowing:
- May be focal (Fig. 13.49A) or generalized (Fig. 13.49B).
- Ophthalmoscopic diagnosis of generalized narrowing is difficult,
- Presence
resence of focal narrowing makes it highly probable that blood pressure is
raised.
- It appears that the presence of arteriolar narrowing is a risk factor for
coronary disease in women.
2 Cotton wool spots: develop in severe hypertension (Fig. 13.50A).
3 Vascular leakage leads to :
- flame-shaped retinal haemorrhages &
- retinal oedema.
• Chronic retinal oedema may result in the deposition of
hard exudates around the fovea in the layer of Henle with
a macular star configuration (Fig. 13.50B).
• Swelling of the optic nerve head is the hallmark of
malignant (accelerated) hypertension. Fig. 13.49 Hypertensive retinopathy. (A) Focal arteriolar
attenuation; (B) generalized arteriolar attenuation
4 Arteriolosclerosis :
involves thickening of the vessel wall, characterized :
Histologically by: 1- intimal hyalinization,
2- medial hypertrophy and
3- endothelial hyperplasia (Fig. 13.51A).
Clinically :
- The most important clinical sign is the presence of changes at Fig. 13.50 Severe hypertensive retinopathy.
arteriovenous crossings (AV nipping – Fig. 13.51B); (A) Cotton wool spots, a few flame-shaped
haemorrhages and arteriolosclerosis;
- although not necessarily indicative of the severity of hypertension, their (B) cotton wool spots, macular star and mild disc
presence makes it probable that hypertension has been present for swelling
many years.
rrowing and +
- The presence of generalized retinal arteriolar narrowing
possibly arteriovenous nipping are related to previously elevated
blood pressure, independent of current blood pressure level. Fig. 13.51 Arteriolosclerosis.
- Mild changes at arteriovenous crossings are seen in patients with (A) Histology shows a thickened vessel wall and narrowing
of the lumen; (B) arteriovenous nipping;
involutional sclerosis in the absence of hypertension.
tension.
 - The grading of arteriolosclerosis is shown as follows (Fig. 13.52):
Grade 1:
• Subtle
ubtle broadening of the arteriolar light reflex,
• mild generalized arteriolar attenuation, particularly of small
branches, and
• vein concealment.
Grade 2:
• Ibvious broadening of the arteriolar light reflex and
• deflection of veins at arteriovenous crossings (Salus sign).
Grade 3:
• ‘Copper-wiring’ of arterioles (Fig. 13.51C). Fig. 13.51 Arteriolosclerosis. (C) ‘copper-wiring’

• Banking of veins distal to arteriovenous crossings (Bonnet sign).

• Tapering of veins on both sides of the crossings (Gunn sign) and
Fig. 13.52 Grading of retinal arteriolosclerosis
right-angled deflection of veins.
Grade 4: ‘Silver-wiring’ of arterioles associated with grade 3 changes.

Choroidopathy
Fig. 13.53 Hypertensive choroidopathy.
(A) Elschnig spots; (B) Siegrist lines; (C) fibrinoid necrosis in a choroidal arteriole in
Choroidopathy is rare but may occur as the result of an acute hypertensive malignant hypertension
crisis (accelerated hypertension) in young adults.

1 Elschnig spots are small black spots surrounded by yellow halos (Fig.
13.53A) which represent focal choroidal infarcts.

2 Siegrist streaks are flecks arranged linearly along choroidal vessels (Fig.
13.53B) indica7ve of fibrinoid necrosis associated with malignant
hypertension (Fig. 13.53C).

3 Exudative retinal detachment, sometimes bilateral, may occur in severe

acute hypertension such as that associated with toxaemia of pregnancy.