202 Hypertensive retinopathy
Salient features
Examination
• Arteriovenous nipping (Fig. 202.1)
• Flame-shaped and blot haemorrhages (see Fig. 201.3B)
Fig. 202.1 (A) Mild retinopathy in an eye with ischaemic optic neuropathy. (B) Severe hypertensive retinopathy. CWS, cotton-wool spots; FH, flame-shaped retina haemorrhage; DS, swelling of the optic disc; AVN, arteriovenous nipping.
(With permission from Wong, Mitchell 2007.)
Fig. 202.2 (A) Grade 1: early and minor changes include increased tortuosity of a retinal vessel and increased reflectiveness (silver wiring) of a retinal artery (at 1 o’clock in this view). (B) Grade 2: increased tortuosity and silver wiring (arrowheads) plus ‘nipping’ of the venules at arteriovenous crossings (arrow). (C) Grade 3: as grade 2 plus flame-shaped retinal haemorrhages and soft ‘cotton-wool’ exudates. (D) Grade 4: swelling of the optic disc (papilloedema), retinal oedema and hard exudates around the fovea, producing a typical ‘macular star’.
(With permission from Forbes, Jackson 2003.)
Diagnosis
This patient has flame-shaped haemorrhages with a macular star (lesions) caused by hypertension (aetiology).
Advanced-level questions
How would you grade hypertensive retinopathy?
Keith–Wagener–Barker classification
This combines the clinical findings of hypertension and atherosclerosis:
• Stage I: arteriolar narrowing
• Stage II: irregular calibre of arterioles
• Stage III: cottonwool exudates; flame and blot haemorrhages, retinal oedema
Note: Subsequent studies have shown that the clinical features and prognosis of patients with stage III and stage IV disease were similar whether or not papilloedema was present; consequently the terms ‘malignant’ and ‘accelerated’ could be used interchangeably. Instead ‘hypertensive crisis’ is used to refer to the syndrome of raised BP complicated by end-organ damage (e.g. stroke, renal failure, myocardial ischaemia or infarction, stage III or IV hypertensive retinopathy).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
