Hypertensive Retinopathy and Sclerotic Changes Definition

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Arterial changes in hypertension are primarily caused byvasospasm; in arteriosclerosis they are the result of thickening of the wall of the arteriole.

Epidemiology: Arterial hypertension in particular figures prominently in clinical settings.

Vascular changes due to arterial hypertension are the most frequent cause of retinal vein occlusion.

Pathogenesis: High blood pressure can cause breakdown of the blood-retina barrier or obliteration of capillaries. This results in intraretinal bleeding, cotton-wool spots, retinal edema, or swelling of the optic disk.

Symptoms: Patients with high blood pressure frequently suffer from headache or eye pain. Impaired vision or loss of visual acuity only occurs in stage III or IV hypertensive vascular changes. Arteriosclerosis does not exhibit any ocular symptoms.

Diagnostic considerations: Hypertensive and arteriosclerotic changes in the fundus are diagnosed by ophthalmoscopy, preferably with the pupil dilated (Tables 12.3 and 12.4). Changes in the retinal vasculature are frequent findings; choroidal infarctions are rare in acute hypertension (Elschnig's spots: circumscribed atrophy and proliferation of pigment epithelium in the infarcted area).

Differential diagnosis: Ophthalmoscopy should be performed to exclude other vascular retinal disorders such as diabetic retinopathy. Diabetic reti-nopathy is primarily characterized by parenchymal and vascular changes; a differential diagnosis is made by confirming or excluding the systemic underlying disorder.

Treatment: Treating the underlying disorder is crucial where fundus changes due to arterial retinopathy are present. Blood pressure should be reduced to below 140/90 mm Hg. Fundus changes due to arteriosclerosis are untreat-able.

Table 12.3 Stages of hypertensive vascular changes (as described by Keith, Wagener, and Barker)

Stage

Characteristics

Stage I:

Constricted, tortuous arterioles.

Stage II:

Severe vascular constriction and Gunn's crossing sign. The column of venous blood is constricted by the sclerotic artery at an arterio-venous crossing.

Stage III:

Retinal hemorrhages, hard exudates, cotton-wool spots, retinal edema (Fig. 12.20)

Stage IV:

Papilledema

The WHO distinguishes between hypertensive retinopathy (stages I and II) and malignant hypertensive retinopathy (stages III and IV)

Table 12.4

Stages of arteriosclerotic vascular changes (as described by Scheie)

Stage

Characteristics

Stage I:

Widening of arteriole reflexes

Stage II:

Arteriovenous crossing sign

Stage III:

Copper-wire arteries (copper colored arterial reflex)

Stage IV:

Silver-wire arteries (silver colored arterial reflex)

Fig. 12.20 Typical findings in this stage include hemorrhages (here readily visible) and cottonwool spots.

— Hypertensive retinopathy (Stage III).

— Hypertensive retinopathy (Stage III).

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Fig. 12.20 Typical findings in this stage include hemorrhages (here readily visible) and cottonwool spots.

Prophylaxis: Regular blood pressure monitoring and ophthalmoscopic examination of the fundus are required to minimize the risk of complications (see below).

Clinical course and complications: Sequelae of arteriosclerotic and hypertensive vascular changes include retinal artery and vein occlusion and the formation of macroaneurysms that can lead to vitreous hemorrhage. In the presence of papilledema, the subsequent atrophy of the optic nerve can produce lasting and occasionally severe loss of visual acuity.

Prognosis: In some cases, the complications described above are unavoidable despite well controlled blood pressure.

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