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Original Article

Evaluation of hypertensive retinopathy in


patients of essential hypertension with high
serum lipids
Rajendra P. Gupta, Sonal Gupta, Abha Gahlot, Dhavat Sukharamwala, Jagruti Vashi
Department of Ophthalmology, Padmashree Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth Pimpri, Pune, India

ABSTRACT

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Purpose: To evaluate the role of hyperlipidemia on fundus


changes in hypertensive patients and to correlate the above
findings with components of lipid profile. Materials and
Methods: A cross-sectional study was carried out in 100 patients
who were diagnosed to have systemic hypertension. Patients
suffering from diabetes, high myopia, patients with hazy ocular
media, and other retinal vascular disorders were excluded from
the study. A detailed evaluation of patients hypertensive status
was carried out by a physician after ruling out secondary causes
of hypertension. Their detailed ophthalmological examination
was carried out. All the patients were investigated for fasting
serum lipid profile. Results: Out of the 100 patients with essential
hypertension, 69 (69%) had retinopathy and the remaining 31
(31%) subjects having retinopathy were mainly concentrated
in the 6th decade (69.70%), increasing thereafter up to 83.78%
who were over 60 years of age. This shows the increasing
prevalence of hypertensive retinopathy with increasing age. No
sex preponderance toward developing retinopathy was found
in this study (o < 0.29). A positive correlation of hypertensive
retinopathy was found with total cholesterol (P < 0.002),
low-density lipoprotein (LDL)-cholesterol (P < 0.0001),
Serum triglycerides (P < 0.01), and an low-density lipoprotein:
high-density lipoprotein (LDL:HDL) ratio (P < 0.002).
Conclusion: This study proved a definite association between
serum lipid parameters and the prevalence of hypertensive
retinopathy.
Keywords: Dyslipidemia, high-density lipoprotein,
hypertensive retinopathy, Keith Wagner Barker classification,
low-density lipoprotein

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DOI:
10.4103/0975-2870.110307

asymptomatic, readily detectable, usually treatable, and often


leads to lethal complications if left untreated.
Hypertensive retinopathy is among the vascular complications
of essential hypertension. It is known that the auto-regulation
of retinal circulation fails as blood pressure increases beyond a
critical limit. However, elevated blood pressure alone does not
fully account for the extent of retinopathy.[1]
Dyslipidemia in hypertensive patients is itself known to be
a predisposing risk factor, an aggravating or complicating
factor.[2] Hypertension and hyperlipidemia not only accelerate
atherogenesis but also cause degenerative changes in the
walls of large- and medium-sized arteries,[3] which accelerate
cerebrovascular hemorrhage,[4] ischemic heart disease,[5] stroke,
and cardiac arrest.[6-8]
Hence, this study helps to assess the association between
hypertensive retinopathy in patients of essential hypertension
with an altered serum lipid profile, with the aim of preserving
vision by tailoring a lipid-lowering treatment.

Introduction

Materials and Methods

Elevated blood pressure is the most important public health


problem in developing and developed countries. It is common,

A cross-sectional study was performed on 100 patients


who were diagnosed to have essential hypertension by a

Address for correspondence:


Dr. Rajendra P. Gupta, Dr. D. Y. Patil Medical College, Pimpri, Pune, India. E-mail: drrpgupta51@gmail.com
Medical Journal of Dr. D.Y. Patil University | April-June 2013 | Vol 6 | Issue 2

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Gupta, et al.: Hypertensive retinopathy in essential hypertensive patients with high serum lipids

physician after thorough evaluation. Patients suffering


from diabetes, high myopia, patients with hazy ocular
media in both eyes, and other retinal vascular disorders
were excluded from the study. A detailed ophthalmological
examination included best corrected visual acuity, anterior
segment examination using slit lamp and posterior segment

examination by slit lamp biomicroscopy using 90D, and


indirect ophthalmoscopy followed by fundus photography
[Figures 1-3]. Staging of hypertensive retinopathy was carried
out using Modified Keith Wagner Barker Classification.[9]
Patients were investigated for complete fasting serum lipid
profile. After complete evaluation, patients were counseled
and appropriate treatment reference was advised.
For different groups and parameters, mean and standard
deviations were calculated. Means of the relative groups were
compared using Students t tests. The Chi square test was
used to identify the independence of the groups and the level
of different parameters.

Results

Figure 1: Grade II hypertensive retinopathy

Figure 2: Grade III hypertensive retinopathy

After satisfying the selection criteria, 100 patients were included


in this study. Out of 100 patients, 31 patients had a normal
fundus and 69 patients had retinopathy in both eyes. Each
patient had retinopathy in both eyes of the same grade. The
mean age, duration of hypertension, systolic BP, diastolic BP,
total cholesterol, low-density lipoprotein (LDL)-cholesterol,
serum trigylcerides, and the low-density lipoprotein:highdensity lipoprotein (LDL:HDL) ratio were high compared
with those who did not show any signs of retinopathy and the
association was statistically significant. Only the mean fasting
blood sugar level and serum HDL level associations were not
statistically significant.
Among the 100 patients studied, 11 patients belong to the
31-40-year age group. Of these 05 (45.45%) had retinopathy
whereas 06 (54.55%) did not. The next category consisting
of 19 patients belong to the 41-50-year age group, of which
10 (52.63%) had retinopathy, whereas 09 (47.37%) showed
no retinopathy. Another category consisted of 33 patients
belonging to the 51-60-year age group, out of which 23
(69.70%) patients had retinopathy, whereas 10 (30.30%)
patients had no retinopathy. In the last category, i.e. age above
60 years, there were 37 patients, of which 31 (83.78%) had
retinopathy and 06 (16.22%) had no retinopathy. In our study,
we found that hypertensive retinopathy increases significantly
with increase in age as the Chi square value is equal to 9.073
with a 3 degree of freedom (P = 0.036). We also found that
retinopathy increased significantly above 50 years of age.
There were 64 males and 36 females in our study group. Out
of these, 47 (73.44%) males and 22 (61.11%) females had
retinopathy, and 17 (26.56%) males and 14 (38.89%) females
had no retinopathy.

Figure 3: Grade IV hypertensive retinopathy

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Of the 100 patients, 47 patients had hypertension since


0-5 years. Of these, 18 (38.3%) had retinopathy of varying
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Gupta, et al.: Hypertensive retinopathy in essential hypertensive patients with high serum lipids

degrees, whereas 29 (61.7%) had no retinopathy. There were 28


patients who had hypertension since age 6-10 years, of which
26 (92.86%) patients had retinopathy, whereas 02 (7.14%)
patients had no retinopathy. The next group of 18 patients
had hypertension since age 10-15 years, and all these patients
had retinopathy. Among the last group of seven patients who
had hypertension since >15 years, all had retinopathy. Overall,
the relationship between various grades of retinopathy and
duration was statistically significant (P < 0.0001).
Out of the 100 patients, 71 had total serum cholesterol
within normal limits (<200 mg/dl). Of these, 41 (57.7%)
patients had retinopathy, whereas 30 (42.25%) patients had
no retinopathy. The next group of 23 patients had total serum
cholesterol between 200 and 239 mg/dl, which is considered to
be borderline. Of these, 22 (95.65%) patients had retinopathy,
whereas 1 (4.35%) patient had no retinopathy. The last group
of six patients had serum total cholesterol levels of >240, which
is considered to be abnormal. Of these, 6 (100%) patients had
retinopathy. Overall, the increase in total serum cholesterol
levels correlated well with the increasing severity of retinopathy
(P < 0.0008) [Table 1].
Out of the 100 patients studied, 62 (62%) had serum LDLcholesterol levels of <130 mg/dl (normal). of these, 24 (38.7%)
had no retinopathy, whereas 38 (61.29%) had retinopathy of
varying grades. the next group of 15 (15%) had serum LDLcholesterol levels between 130 and 159 mg/dl (borderline), of

which 05 (33.3%) had no retinopathy, whereas 10 (66.67%)


had retinopathy. the last group of 23 (23%) patients had
serum LDL-cholesterol levels of >160 mg/dl (abnormal),
of which 02 (8.70%) patients had no retinopathy, whereas
21 (91.30%) had retinopathy. Overall, the increasing level
of serum LDL-cholesterol showed statistically significant
correlation with the grades of hypertensive retinopathy
(P < 0.0001) [Table 2].
Out of the 100 patients, only 1 (1%) patient had serum HDLcholesterol levels of >60 mg/dl and had retinopathy. the next
group of 75 patients had serum HDL-cholesterol levels in the
range 36-60 mg/dl (borderline), of which 54 (72%) patients
had retinopathy and 21 (28%) had no retinopathy. the last
group of 24 patients had serum HDL-C levels of <35 mg/dl
(abnormal), of which 14 (58.33%) patients had retinopathy,
whereas 10 (41.67%) did not. Overall at 90%, the HDL levels
were significantly lower in hypertensive retinopathy patients
than in normal patients (P = 0.061) [Table 3].
Out of the 100 patients, 40 (40%) patients had an LDL:HDL
ratio of <2.5, of which 25 (62.5%) had varying grades of
retinopathy, whereas 15 (37.5%) had no retinopathy.
The next group of 45 (45%) patients had a serum LDL:HDL
ratio of between 2.5 and 5.1. Of these, 29 (64.4%) had
retinopathy, whereas 16 (35.56%) had no retinopathy. The last
group of 15 (15%) patients had a serum LDL HDL-C ratio

Table 1: Relationship of grades of retinopathy with serum total


cholesterol

Table 2: Relationship of serum low-density lipoprotein-cholesterol


with grades of retinopathy

Grade of
retinopathy

Grade of
Serum LDL-cholesterol levels (mg/dl)[10]
retinopathy <130
130-159
<160
Total
(N) (borderline) (abnormal)
N
24
05
02
31
I
20
03
00
23
II
15
04
09
28
III
03
03
10
16
IV
0
0
2
2
Total
62
15
23
100

Normal
I
II
III
IV
Total

Serum total cholesterol levels


(mg/dl)[10]
<200
200-239
>240
Total
30
1
0
31
19
04
0
23
15
10
03
28
07
07
02
16
0
1
1
2
71
23
6
100

Mean

17.8354 13.52
184.83 14.13
209.357 28.78
215.3175 32.39
225.60 30.30

Table 3: Relationship between serum high-density lipoproteincholesterol with grades of retinopathy

N
I
II
III
IV
Total

106 28.9
98 27.4
132 47.9
170.12 36.14
172.98 34.12

2 = 30.952, P < 0.0001, LDL: Low-density lipoprotein

2 = 23.49, P < 0.0008

Grade of
retinopathy

Mean

Serum HDL-cholesterol levels (mg/dl)


Mean
>60
36-60
<35
Total
(desirable) (borderline) (abnormal)
0
21
10
31
39 7.26
01
19
03
23
40.5 9.79
00
24
04
28 39.39 5.36
00
10
06
16 35.37 6.74
0
1
1
2
30.37 4.74
01
75
24
100
10

2=8.841, P=0.1827 (NS), HDL: High-density lipoprotein

Medical Journal of Dr. D.Y. Patil University | April-June 2013 | Vol 6 | Issue 2

Table 4: Relationship between serum low-density lipoprotein and


high-density lipoprotein ratio with grades of retinopathy
Grade of
retinopathy

N
I
II
III
IV
Total

Serum LDL:HDL-cholesterol ratio[10]


< 2.5
2.5-5.0
> 5.00
Total
15
16
0
31
14
08
01
23
11
12
05
28
00
09
07
16
0
0
2
2
40
45
15
100

Mean
2.78 0.84
2.70 1.69
3.56 1.68
4.98 1.37
4.98 1.37

2=27.62, P=0.0001, LDL: Low-density lipoprotein, HDL: High-density lipoprotein

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Gupta, et al.: Hypertensive retinopathy in essential hypertensive patients with high serum lipids

>5.00. Of these, 15 (100%) patients had retinopathy. Overall,


the increasing levels of LDL:HDL-cholesterol correlated
positively with increasing severity of retinopathies, which was
statistically significant (P = 0.0001) [Table 4].
Out of the 100 patients, 68 (68%) patients had serum
triglyceride levels of <150 (normal), of which 42 (61.76%)
patients had retinopathy, whereas 26 (38.24%) patients had
no retinopathy. Of the remaining 32 (32%) patients who had
serum triglyceride levels of >150 mg/dl, 27 (84.38%) patients
had retinopathy, whereas 05 (15.63%) patients did not.
Overall, serum triglyceride levels correlated positively with
the increasing severity of retinopathy, which was statistically
significant (P = 0.01) [Table 5].

Discussion
The mean age of patients in the present study population was
56.50 21.00 years, ranging from 35 to 78 years. Out of these,
69 patients belonged to the retinopathy group with a mean age
of 56.00 17.00 years and 31 patients had normal fundus, with
a mean age of 50.50 15.0 years (P < 0.00l). in a study carried
out by Bastola et al.,[11] the mean age of the study group was
58.5 years (SD = 9.2 years; range = 33-48).
There were 64 males and 36 females in this study group,
out of which 47 (73%) males and 22 (61.11%) females had
retinopathy. Although 17 (27%) males and 14 (38.89%)
females had no signs of retinopathy, there was no significant
sex preponderance (P < 0.29). In the past, there have been fewer
studies of the incidence of hypertensive retinopathy and none
of them have shown sex preponderance.
In our study, there was an increased incidence of hypertensive
retinopathy in patients having high serum cholesterol level
and this association was statistically significant (P < 0.0008).
Similarly, Bastola et al.,[11] in their study, also showed that
there was a statistically significant difference in the mean
serum cholesterol level (F = 10.38; P < 0.001) of patients
with normal fundus and in those with different grades of

Normal
I
II
III
IV
Total

168

Serum triglycerides levels (mg/dl)[10]


< 150
> 150
Total
26
05
31
17
06
23
17
11
28
6
10
16
2
0
2
68
32
100

Badhu et al. also assessed the serum level of LDL in


hypertensive retinopathy. Their results showed a statistically
significant (P < 0.0196) higher serum level of LDL-cholesterol
in hypertensive patients with retinopathy (mean SD = 2.45
1.76 mmol/l, SE = 0.33 and 95% CI = 1.79-3.11 vs. mean
SD = 1.6 0.4 mmol/l, SE = 0.08 and 95% CI = 1.44-1.76).
The study concluded that an increased serum level of LDLcholesterol is associated with a higher incidence of hypertensive
retinopathy,[12] which corroborates with our findings. Bastola
et al.[11] also showed a significant correlation between serum
LDL-cholesterol and grade II and higher hypertensive
retinopathy (F = 30.39; P < 0.001).
The mean serum HDL-cholesterol value for the retinopathy
group was 38.68 and that for the no retinopathy group was
39. There was no significant association between serum HDLcholesterol and retinopathy. Bastola et al.[11] also showed similar
findings. No other study has reported any correlation between
serum HDL-cholesterol and hypertensive retinopathy so far.
The association of LDL:HDL-cholesterol ratio was found to
be statistically significant (P < 0.0001). In the literature, no
such correlation has been reported so far.
We found a significant association between serum triglycerides
and hypertensive retinopathy patients (P < 0.01). Mean
triglycerides levels were also found to be high in grade II and
higher hypertensive retinopathy patients in a study carried out
by Bastola et al.[11]
Thus, this study shows a definite association between serum
lipid parameters and the prevalence of hypertensive retinopathy.

Conclusion

Table 5: Relationship of serum triglycerides with grades


of retinopathy
Grades of
retinopathy

hypertensive retinopathy. In general, the association of serum


total cholesterol levels was highly significant (P < 0.0008).
Similarly, we found a significant association between serum
LDL-cholesterol and the severity of the retinopathy (P <
0.0001).

Mean
113.38 36.83
121.56 53.66
144.71 55.45
187.93 111.1
160.43 87.1

Hypertensive retinopathy has been found to occur in people


above 35 years of age, with a mean age of 56 years. There was
no sex preponderance. There was an increase in incidence
of hypertensive retinopathy with increase of serum total
cholesterol, serum LDL, and serum triglycerides. However,
no correlation was found between HDL-cholesterol and
hypertensive retinopathy.
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Gupta, et al.: Hypertensive retinopathy in essential hypertensive patients with high serum lipids

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How to cite this article: Gupta RP, Gupta S, Gahlot A, Sukharamwala D, Vashi
J. Evaluation of hypertensive retinopathy in patients of essential hypertension
with high serum lipids. Med J DY Patil Univ 2013;6:165-9.
Source of Support: Nil. Conflict of Interest: None declared.

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