Moreover, hypertension can also cause occlusion of major retinal vessels such as the branch retinal artery, central retinal artery, branch retinal vein and central retinal vein. The arteriosclerotic changes of hypertensive retinopathy are caused by chronically elevated blood pressure.
Hypertensive retinopathy includes two disease processes. The acute effects of systemic arterial hypertension are a result of vasospasm to autoregulate perfusion.
In addition, the incidence of blood pressure increases with age. Men are more affected than women in age groups less than 45 years old and women are more affected in age groups greater than 65 years old. The arteriosclerotic changes of hypertensive retinopathy are caused by chronically elevated blood pressure, defined as SBP greater than mmHg and DBP greater than 90 mmHg. Essential hypertension is a polygenic disease with multiple modifiable environmental factors contributing to the disease.
In addition, genetic factors have been found to be associated with a higher risk of hypertensive retinopathy. Risk factors for essential hypertension include high salt diet, obesity, tobacco use, alcohol, family history, stress, and ethnic background. The major risk for arteriosclerotic hypertensive retinopathy is the duration of elevated blood pressure.
The major risk factor for malignant hypertension is the degree of blood pressure elevation over normal. Some studies suggest a genetic influence on retinal vascular caliber. A population-based study indicated four novel loci 19q13, 6q24, 12q24, and 5q14 as significantly associated with retinal venular caliber.
Hypertensive retinopathy goes through vasoconstrictive, sclerotic, and exudative phases based upon the extent of hypertension control. In the vasoconstrictive phase , due to the elevated luminal pressures, local autoregulatory mechanisms cause retinal arteriole narrowing and vasospasm to reduce flow.
In the sclerotic phase , the layers of the endothelial wall undergo changes such as intimal thickening, medial hyperplasia, and hyaline degradation in the arteriolar [10] worsening arteriolar narrowing, AV crossing changes, and silver and copper wiring. In the exudative phase , there is a disruption of the blood-brain barrier and leakage of plasma and blood causing retinal hemorrhages, hard exudates, retinal ischemia, and necrosis of smooth muscle.
Retinal hemorrhages Figure develop when necrotic vessels bleed into either the superficial retina nerve fiber layer flame shaped hemorrhage or the inner retina dot blot hemorrhage. Ischemia to the nerve fibers leads to decreased axoplasmic flow, nerve swelling, and ultimately fluffy opacification. Exudates Figure 2 occur later in the course of disease, surrounding areas of hemorrhage, as a result of lipid accumulation.
Malignant hypertension can cause papilledema Figure 3 , which is a result of both leakage and ischemia of arterioles supplying the optic disc that undergo fibrinous necrosis.
Ischemia causes optic nerve edema, while leakage causes hemorrhage and disc edema. Of note, the severity and degree of malignant hypertension corresponds to changes of renal function highlighting the multi-organ damage caused by systemic microvascular dysfunction.
Routine blood pressure monitoring and treatment will prevent hypertensive retinopathy from developing. Hypertensive retinopathy is diagnosed based upon its clinical appearance on dilated fundoscopic exam and coexistent hypertension.
The history should focus upon the hypertension disease history, symptoms of hypertension, and history of its complications. To gauge hypertension disease severity, patients should be asked about their severity and duration of hypertension, and about the medications taken as well as compliance. Symptoms of hypertension to ask about include headaches, eye pain, reduced visual acuity, focal neurological deficits, chest pain, shortness of breath, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, and palpitations.
Patients should be asked about the complications of hypertension, including history of stroke or transient ischemic attack, history of coronary or peripheral vascular disease, and history of heart failure.
The physical exam on a patient with hypertension includes vital signs, cardiovascular exam, pulmonary exam, neurological exam, and dilated fundoscopy. Vital signs should obviously focus on blood pressure. Key elements of the cardiovascular exam include heart sounds gallops or murmurs , carotid or renal bruits, and peripheral pulses.
Pulmonary exam can identify signs of heart failure if rales are present. Hypertension with no known cause primary; formerly, essential It causes sudden, painless, unilateral, and usually severe vision loss.
It causes painless vision loss, ranging from mild to severe, and usually occurs suddenly. Diagnosis is Also, hypertension combined with diabetes greatly increases risk of vision loss. Patients with hypertensive retinopathy are at high risk of hypertensive damage to other end organs.
Symptoms usually do not develop until late in the disease and include blurred vision or visual field defects. In the early stages, funduscopy identifies arteriolar constriction, with a decrease in the ratio of the width of the retinal arterioles to the retinal venules. Arteriosclerosis with moderate vascular wall changes copper wiring to more severe vascular wall hyperplasia and thickening silver wiring. Sometimes total vascular occlusion occurs.
Arteriovenous nicking is a major predisposing factor to the development of a branch retinal vein occlusion. Moderate hypertensive retinopathy is characterized by thinned, straight arteries, intraretinal hemorrhages, and yellow hard exudates.
This image shows retinal arteriolar narrowing due to thickening and opacification of arteriolar walls copper wiring caused by hypertensive arteriosclerosis. The cardinal funduscopic feature of malignant hypertension is optic disk swelling, which appears as blurring and elevation of disk margins.
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The prognosis is worse for higher grades of HR. Grades 3 and 4 are associated with higher rates of:. People with uncontrolled hypertension and grade 4 HR, sometimes called the malignant stage, have a generally poor prognosis for survival, according to the journal Retinal Physician. Structural changes to the arteries in the retina are generally not reversible. Even with treatment, patients diagnosed with HR are at a higher risk for retinal artery and vein occlusions, and other problems of the retina.
If you have high blood pressure or HR, your primary care doctor can work with your eye doctor ophthalmologist to determine an appropriate treatment plan and monitor your condition. To prevent HR, take steps to avoid high blood pressure. Here are a few things you can do:. You can manage high blood pressure with more than medication. We'll show you seven home remedies for high blood pressure, including exercising….
High blood pressure is often associated with few or no symptoms. Many people have it for years without knowing it. Learn more. Checking your blood pressure at home with a manual or automated device can help you monitor your health between doctor visits. Malignant hypertension is high blood pressure accompanied by new symptoms, such as those related to the eye or other organs. Get the facts on causes….
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