HYPERTENSIVE

RETINOPATHY
ANGEL DAS
 Hypertensive Retinopathy
• Fundus changes that occur in patients with severe hypertension
• Clinical presentation includes changes of
-Retinopathy
-Choroidopathy
-Optic neuropathy
 pathogenesis
• 3 factors play role in pathogenesis
1. Vasoconstriction
2. Arteriosclerotic changes
3. Increased vascular permeability
 Pathophysiology

Systemic chronic Narrowing of

Arteriosclerosis
hypertension retinal arterioles

Increased
Retinal
Hypoxia capillary
Ischaemia
permeability

Focal Retinal Oedema, retinal

haemorrhage,cotton wool spots, hard
exudates
 Clinical types
Clinically hypertensive fundus changes can be described as
• Chronic hypertensive retinopathy
• Malignant/acute hypertensive retinopathy
 Chronic hypertensive retinopathy
• Usually asypmtomatic
• Clinical situations include
1. Hypertension with involutinary ( senile)
sclerosis:
elderly patients (> 50 yrs ),fundus changes comprise augmented arteriosclerotic retinopathy.
2.Chronic hypertension with compensatory
arteriolar sclerosis

• Seen in young individuals

• young arterioles respond to HTN by prolifrative and
fibrous changes in media
• In the kidneys there will be chronic
glomerulonephritis
• so known as albuminuric or renal retinopathy
Normal Fundus
 Fundus Changes

• Generalized arteriolar narrowing

• Focal arteriolar narrowing
• A-V nicking
-hallmark of HR
• Salu’s sign – deflection of veins at A-V crossing
• Bonnet sign – banking of veins distal to A-V crossing
• Gunn sign – tapering of veins on either side of crossing
• Arteriolar Reflex Changes
-bright, thin, linear reflex –Normal
-diffuse, less bright reflex –Grade I/II
-Copper wiring
-Silver wiring
• Superficial retinal haemorrhages
• Hard exudates
• Cotton wool spots
 Malignant hypertension
• rapid progression of the hypertensive state in a patient with relatively young
arterioles undefended by sclerosis
• There will be retinopathy , choroidopathy & optic neuropathy
• It is asso. With renal insufficiency
 Choroidopathy

• Elschnig’s spots- focal areas infarcted retinal pigment

epithelium
• Siegrist streaks- due to fibrinoid necrosis in malignant
hypertension
 Grade I

 Mild generalised arteriolar

attenuation

 Broadening of arteriolar
light reflex

 Vein concealment
 Grade II

 Marked generalised narrowing

and focal attenuation of
artertioles

 Salus’ Sign (deflection of veins

at AV crossings)
 Grade III
Bonnet sign Gunn Sign

 Copper wiring of arterioles

 Bonnet Sign (banking of

veins distal to av crossings)

 Gunn Sign (tapering of vein

on either side of av crossings)

 Flame shaped haemorrhages,

 Cotton wool spots
 Hard exudates
 Grade IV

 Grade III changes

 Silver wiring of
arterioles

 Papilloedema
• Scheie classification
 Management
Mild HR BP control only

Moderate HR BP control
+
Assess cholesterol levels & if indicated cholesterol
lowering agents
Accelerated HR Urgent anti hypertensive management by stepwise
control of BP over a few hours
 BP >160/100mm Hg- >
200/130mm Hg

 Narrowing of nasal arterioles-

generalised

 Cotton wool spots; retinal

hemmorhages- retinal hypoxia

 ‘Macular star’ – ‘flat macular

detachment’
 Management
• Changes are reversible , disappear after delivery
• In preorganic stage : conservative treatment , pregnancy is continued under
close observation
• Advent of hypoxic retinopathy( cotton wool spots,hemorrhages,retinal
edema): indication for termination of pregnancy ,otherwise permanent visual
loss or even loss of life may occur.