Hypertensive retinopathy

Question 1

What is high blood pressure?

Answer 1

BP that is raised > 140/90mmHg on at least two occasions

NICE Guidelines

Question 2

What is the prevalence of high blood pressure ?

Answer 2

high
- the global prevalence of 40%
In adults >25 yrs in 2008 (WHO 2016)

Question 3

What is high blood pressure a major risk factor for ?

Answer 3

heart disease , stroke , renal problems and visual impairment

Question 4

What can be the first indication a patient has high blood pressure ?

Answer 4

changes at the back of the eye

can then refer them to gp to check for high bp

Question 5

What is malignant hypertension?

Answer 5

very high bp
rare
Systolic > 200mmHg
Diastolic > 140mmHg

Question 6

Who are at risk factors for raised BP ?

Answer 6

• Age
• Family history
• Obesity
• Smoking
• African-Caribbean race

Question 7

What are the ocular complications of raised BP ?

Answer 7

• Cranial nerve palsies
• Sub-conjunctival haemorrhages
• Hypertensive retinopathy

Question 8

What is hypertensive retinopathy?

Answer 8

is a change of the back of the eye you see during ophthalmoscopy - direct or slit lamp or binocular indirect ophthalmoscopy

Question 9

Where do systemic disease tend to be present ?

Answer 9

• in bilateral changes at the back of the eye i.e the signs are present in both eyes
• one eye might be more but in both eyes

Question 10

What does hypertensive retinopathy affect ?

Answer 10

both eyes

Question 11

What are the different grades of hypertensive retinopathy ?

Answer 11

grade 1 - 4

each grade increases in severity

Question 12

What is grade 1 hypertensive retinopathy ?

Answer 12

the early changes are
- Arteriosclerosis = hardening or loss of elasticity of small blood vessel walls

-Mild to moderate narrowing or sclerosis of the retinal arterioles

-Vasospasm of arterial walls
Normal A/V ratio reduced when examining the back of the eye (artery to vein)

-Increased venous tortuosity may also be seen- veins look more torturous- more squiggly

Question 13

What is the optometric management for grade 1 hypertensive retinopathy ?

Answer 13

Refer to GP if not already being treated for raised bP

Question 14

What is grade 2 hypertensive retinopathy ?

Answer 14

-Moderate to marked narrowing of the arterioles
Local and or generalised

• Arteriovenous crossing changes
• Increase in the light reflex
• there can be focal arteriole narrowing (could be reversible )
• there is a reduced A:V ration e.g 1:3 rather than 2:3

Question 15

What is nipping of Gunns signs in grade 2 HR?

Answer 15

Thinning of venuole at an arteriole crossing - LOOKS as though the blood vessel has been nipped or pressed on

• Classic sign of systemic hypertension
• May persist even if hypertension under control
• important to get full POH from px so if being managed dont need to be referred to GP

Question 16

What is the changes in life reflex called ? (grade 2)

Answer 16

-Copper wire

Question 17

what does copper wire in grade 2 HR do?

Answer 17

• Increase in elastic and muscular components of artery wall- change in colour of artery
• Hypertensive arteriosclerosis – increased light reflex

Question 18

what is the tometric management for GRADE 2 HR?

Answer 18

Refer to GP – for a cardiovascular check, BP check.- if not already being treated

Question 19

What is grade 3 hypertensive retinopathy ?

Answer 19

hypertension not being treated or being treated but BP is not well controlled

Question 20

What are the changes associated with grade 3 hypertensive retinopathy ?

Answer 20

-Typically BP Dystolic 110-115mmHg

• you are likely to see Grade 2 arterial narrowing and focal constriction
• see changes such as
  
  • Cotton wool spots
  • Retinal haemorrhages
    - Hard exudates
    - Retinal oedema

Question 21

What are cotton wool spots ?

Answer 21

-Occlusion of pre-capillary arterioles

How many CWS can you see?

Question 22

What are the CWS caused by ?

Answer 22

• by a microinfarction of retinal nerve fibre layer- Axon swells and creates opaque appearance in the retinal nerve fibre layer

Question 23

What do you notice with CWS as they are in the retinal nerve fibre layer ?

Answer 23

they do obscure underlying blood vessels

Question 24

What is vascular leakage ?

Answer 24

haemorrhages

• with HR - haemorrhages tend to be flame shapes
• they are superficial and follow the path of the nerve fibre layer

Question 25

What does vascular leakage result in ?

Answer 25

• retinal oedema

- also hard exudates- which are Lipo-proteins being released- gives yellow waxy appearance on fundus

Question 26

How can you view the vascular leakage?

Answer 26

• Better viewed by SL BIO
• as it gives you a tereoscopic view
• may need to do OCT to detect macular oedema

Question 27

What happens if these changes of vascular leakage are happening over a period of time ?

Answer 27

chronic

-can result in chronic macular oedema

Question 28

What are the features of chronic macular oedema

?

Answer 28

hard exudates deposited around the fovea = macular star

Question 29

What is the optometric management of grade 3 ?

Answer 29

-Rapid referral to GP for cardiovascular check

Question 30

What happens if blood pressure not controlled?

Answer 30

changes in back of eye continue

-lead to the severe form of HR

Question 31

What is the most severe form of HR?

Answer 31

Grade 4

Question 32

What is grade 4 HR?

Answer 32

-Occurs in malignant hypertension i.e. Diastolic
130-140mmHg

• YOU HAVE ALL of the features of Grade 3 plus
  Optic disc swelling

Question 33

What are the symptoms of the grade 4 OF HR?

Answer 33

• THE Visual symptoms - reduced VA

- px has Headaches

Question 34

What is the Optometric managament for grade 4 ?

Answer 34

-Refer to A&E

as there is a high risk of ocular, cardiac, renal and cerebral damage