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

Grade

Grade

Grade

Generalised

arteriolar constriction - seen as

`silver wiring` and vascular tortuosities.

As

grade 1 + irregularly located, tight

constrictions - Known as `(AV) nicking` or `AV
nipping`

As

grade 2 + with cotton wool spots and flamehemorrhages

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,Gunns sign)
Right-angled crossing
by venous deflection
Venous distal
banking
(Bonnets 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 exudateslipids 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 :
autoregulation causes
uniform narrowing of
retinal arterioles

Older patients :
arterosclerosis and
autoregulation causes
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
e

Description

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
Stage
4 - Retinal
edema, hard
exudates,
The Scheie
classification
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