Hypertensive retinopathy Flashcards
What is high blood pressure?
BP that is raised > 140/90mmHg on at least two occasions
NICE Guidelines
What is the prevalence of high blood pressure ?
high
- the global prevalence of 40%
In adults >25 yrs in 2008 (WHO 2016)
What is high blood pressure a major risk factor for ?
heart disease , stroke , renal problems and visual impairment
What can be the first indication a patient has high blood pressure ?
changes at the back of the eye
can then refer them to gp to check for high bp
What is malignant hypertension?
very high bp
rare
Systolic > 200mmHg
Diastolic > 140mmHg
Who are at risk factors for raised BP ?
- Age
- Family history
- Obesity
- Smoking
- African-Caribbean race
What are the ocular complications of raised BP ?
- Cranial nerve palsies
- Sub-conjunctival haemorrhages
- Hypertensive retinopathy
What is hypertensive retinopathy?
is a change of the back of the eye you see during ophthalmoscopy - direct or slit lamp or binocular indirect ophthalmoscopy
Where do systemic disease tend to be present ?
- 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
What does hypertensive retinopathy affect ?
both eyes
What are the different grades of hypertensive retinopathy ?
grade 1 - 4
each grade increases in severity
What is grade 1 hypertensive retinopathy ?
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
What is the optometric management for grade 1 hypertensive retinopathy ?
Refer to GP if not already being treated for raised bP
What is grade 2 hypertensive retinopathy ?
-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
What is nipping of Gunns signs in grade 2 HR?
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
What is the changes in life reflex called ? (grade 2)
-Copper wire
what does copper wire in grade 2 HR do?
- Increase in elastic and muscular components of artery wall- change in colour of artery
- Hypertensive arteriosclerosis – increased light reflex
what is the tometric management for GRADE 2 HR?
Refer to GP – for a cardiovascular check, BP check.- if not already being treated
What is grade 3 hypertensive retinopathy ?
hypertension not being treated or being treated but BP is not well controlled
What are the changes associated with grade 3 hypertensive retinopathy ?
-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
What are cotton wool spots ?
-Occlusion of pre-capillary arterioles
How many CWS can you see?
What are the CWS caused by ?
- by a microinfarction of retinal nerve fibre layer- Axon swells and creates opaque appearance in the retinal nerve fibre layer
What do you notice with CWS as they are in the retinal nerve fibre layer ?
they do obscure underlying blood vessels
What is vascular leakage ?
haemorrhages
- with HR - haemorrhages tend to be flame shapes
- they are superficial and follow the path of the nerve fibre layer
What does vascular leakage result in ?
- retinal oedema
- also hard exudates- which are Lipo-proteins being released- gives yellow waxy appearance on fundus
How can you view the vascular leakage?
- Better viewed by SL BIO
- as it gives you a tereoscopic view
- may need to do OCT to detect macular oedema
What happens if these changes of vascular leakage are happening over a period of time ?
chronic
-can result in chronic macular oedema
What are the features of chronic macular oedema
?
hard exudates deposited around the fovea = macular star
What is the optometric management of grade 3 ?
-Rapid referral to GP for cardiovascular check
What happens if blood pressure not controlled?
changes in back of eye continue
-lead to the severe form of HR
What is the most severe form of HR?
Grade 4
What is grade 4 HR?
-Occurs in malignant hypertension i.e. Diastolic
130-140mmHg
- YOU HAVE ALL of the features of Grade 3 plus
Optic disc swelling
What are the symptoms of the grade 4 OF HR?
- THE Visual symptoms - reduced VA
- px has Headaches
What is the Optometric managament for grade 4 ?
-Refer to A&E
as there is a high risk of ocular, cardiac, renal and cerebral damage
