Hypertensive retinopathy

202 Hypertensive retinopathy



Instruction


Examine this patient’s eyes.


Examine this patient’s fundus.



Salient features



History




• Usually no ocular symptoms


• History of hypertension.



Examination




• Arteriovenous nipping (Fig. 202.1)


• Arteriolar narrowing


• Macular star


• Flame-shaped and blot haemorrhages (see Fig. 201.3B)


• Cottonwool exudates (see Fig. 201.3D)


• Papilloedema may or may not be present (Fig. 202.2).


image

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.)


image

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.)


Proceed as follows:



• Tell the examiner that you would like to:


• check the BP

• examine the urine for proteinuria

• examine the heart for left ventricular hypertrophy.


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


• Stage IV: papilloedema.


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).

Related posts:

  1. Permanent cardiac pacemaker/implantable cardioverter-defibrillator
  2. Cauda equina syndrome
  3. Dermatomyositis
  4. Arteriovenous fistula

Stay updated, free articles. Join our Telegram channel
Tags:
Dec 4, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Hypertensive retinopathy

Full access? Get Clinical Tree
Get Clinical Tree app for offline access