HYPERTENSIVE OCULAR DISEASE

FREDDY SITORUSJAKARTA, 25-2-2011

INTRODUCTION

• Systemic hypertension is a common condition associated with significant morbidity and mortality.

• Hypertension confers cardiovascular risk by causing target-organ damage that includes retinopathy in addition to heart disease, stroke, renal insufficiency and peripheral vascular disease.

• The recognition of hypertensive retinopathy and other ocular disease related to hypertension is important in cardiocerebrovascular risk stratification of hypertensive individuals.

Direct ocular effect of hypertension

• Hypertensive retinopathy refers to retinal microvascular signs that are related to raised blood pressure.

This sign can be divided into stages.

• Initial response:

Vasospasm and increase in vasomotor tone, which is seen clinically as generalisedretinal- arteriolar narrowing.

• Chronic arteriosclerosis changes:– Intimal thickening, media wall hyperplasia, and

hyaline degeneration.– manifest as:

• diffuse and focal areas of arteriolar narrowing, • opacification of arteriolar walls ( describe as

silver or copper wiring ), and• compressing of the venules by arteriolar ( term

arteriovenous nipping or nicking)

• More pronounced high blood pressure:The blood-retinal barriers break down, resulting in– Exudation of blood (haemorrhages)– Lipid ( hard exudates)– Ischaemia of nerve fibre layers (known as cotton-

wool spots).

• Severely high blood pressure raised intra cranial pressure and concomitant optic

nerve ischaemia can lead to disc swelling

(papilloedema) referred as severe or malignant hypertension or

hypertensive optic neuropathy.

CLASSIFICATION

• Clinically, sign of hypertensive retinopathy are classified into four grades of increasing severity.

• This system is widely used, but early retinopathy grades are difficult to distinguish, also prognostic implications of early retinopathy hypertensive retinopathy grades are not clear.

• Thus a three grade classification system has been proposedMild, Moderate and Severe retinopathy.

CLASSIFICATION

Hypertension as a risk factor in ocular disease

• Retinal vein occlusionCharacterised clinically by dilated and tortuous retinal veins and the presence of retinal haemorrhages, cotton-wool spots, and edema of macula and optic disc.Patients typically present with poor visual acuity and a relative afferent papillary defect

• Retinal artery occlusion• Central retinal artery occlusion present with

a sudden, painless, unilateral loss of vision.

Typically appears as a cherry red spot

• Occlusion of branch retinal artery, could present with visual field defect, an loss of central vision ( can be slight )

• Ischaemic optic neuropathy.• Is the most frequent acute optic neuropathy

in patient aged over 50.

• Typically present sudden visual loss and optic-disc oedema.

AAN 2009

CONCLUSION

• Sign of hypertensive retinopathy are common and correlated with elevated blood pressure.

• This signs predict stroke.• Prompt recognition and accurate diagnosis of

hypertensive retinopathy have important implication for ocular and general health of individual.

• Ophthalmoscopy is an important skills for all neurologist.