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Hypertensive retinopathy is the term that is used to describe the eye changes that happen in people who have high blood pressure. Hypertension is the name of the condition when the blood pressure is higher than normal for a prolonged period of time. It has profound effects on various parts of the eye, and in particular on the retina (the part of the sensitive inner eye lining that is responsible for vision).
Studies have shown that mild hypertensive retinopathy signs are common, and are seen in nearly 10% of the general adult non-diabetic population. Many of the hypertensive retinopathy signs are commonly seen in 6–15% of non-diabetic adults aged ⩾40 years.
Hypertensive retinopathy signs are associated with other symptoms of the internal organ damage (such as left ventricular hypertrophy, renal impairment) and may be a risk marker of future clinical events, such as stroke, congestive heart failure and cardiovascular mortality.
High blood pressure is one of the major risk factors for development and progression of diabetic retinopathy, and good management of hypertension has been shown to prevent visual loss from diabetic retinopathy. In addition, several retinal diseases such as retinal vascular occlusion (artery and vein occlusion), retinal arteriolar emboli, macroaneurysm, ischemic optic neuropathy and age-related macular degeneration may also be related to hypertension. Unfortunately, there is as yet no evidence that treatment of hypertension prevents vision loss from these conditions.
In management of patients with hypertension, experts have a complete understanding of the relationship of blood pressure and the eye, not just an eye. Sometimes it takes a team of many specialists to get the best recommendations on the hypertensive eye disease.
Symptoms of Hypertensive Retinopathy
Chronic hypertensive retinopathy rarely causes significant visual loss. The changes of the blood vessels are found on a retina exam by an ophthalmologist, and graded according to the changes seen.
What Causes Hypertensive Retinopathy?
Classically, elevated blood pressure results in a series of retinal blood micro-vessels changes called hypertensive retinopathy, which further causes generalized and focal retinal arteriolar narrowing, arteriovenous nicking, retinal hemorrhages, microaneurysms and, in severe cases, optic disc and macular edema.
Chronic blood pressure elevation can lead to hypertensive choroidopathy generally seen in younger patients with pliable vessels that are not yet sclerotic from long-standing hypertension.
Acute elevations in blood pressure that overwhelm the compensatory tone actually harm the choroidal circulation more than the retinal circulation due to the sympathetic innervation of choroid. As a result, the choroidal arterioles constrict considerably initially, which further increases the blood pressure and damages the arterioles.
Risk Factors for Hypertensive Retinopathy
It is well known that hypertensive retinopathy is related to both the presence and severity of hypertension. People whose blood pressure was elevated even with the use of medications had a higher risk to develop retinopathy, compared with those whose blood pressure was controlled.
Racial variations in the prevalence of retinopathy show that the highest rates of retinopathy are observed among Chinese (17.2%) and the lowest among White (11.9%), and Black populations (13.9%).
With respect to gender, higher incidence has been reported among men except for Black populations. In Asian populations, Japanese and Malays living in urban areas, showed lower incidence of retinopathy (7.7 and 6%, respectively).
Numerous studies have found and described the genetic influence on the development of retinal vascular caliber within families and twins. The genetic inheritance of the retinal blood vessel caliber, and the arteriovenule ratio can possibly explain why this disease runs in the families.
How Is Hypertensive Retinopathy Diagnosed?
Hypertensive retinopathy can be silent for years not producing any symptoms. That is why it is so important to have eye exams if you are diagnosed with the high blood pressure.
The association between blood pressure and retinal microvascular signs is weaker with age, possibly reflecting greater sclerosis of retinal arterioles in older persons.
It is important for doctors to be aware that some retinal microvascular signs of hypertension may also be seen in other systemic and ocular conditions, such as:
diabetic retinopathy,
radiation retinopathy,
anemic/leukemic retinopathy,
trauma,
human immunodeficiency virus and other infections.
Appropriate investigations (imaging studies, labs, consultations with other specialists) may be necessary to rule out other important diseases that may masquerade as hypertensive retinopathy.
Ophthalmoscope
This is a basic exam a doctor will do to see the condition of your retina. An ophthalmologist uses many fancy instruments to visualize the blood vessels and retina inside your eye. here is what they see:
The initial response is diffuse and localized vasospasm of the retinal arterioles with consequent narrowing (generalized arteriolar narrowing and focal arteriolar narrowing (FAN), respectively).
Arteriolar narrowing is a defining sign of hypertensive retinopathy and reflects vasoconstriction as an autoregulatory response in an attempt to control the volume of blood received by the retinal capillary bed. It is most commonly seen in the early phase of hypertensive retinopathy before the onset of sclerosis and can be detected even in children with hypertension.
If the blood pressure is not controlled and remains high, there is compression of venules by structural changes in the arterioles, resulting in arteriovenous nicking. Severe hypertension leads ultimately to progression to an ‘exudative’ stage in which flame-shaped retinal hemorrhages and cotton wool spots are observed; and finally to a ‘malignant’ stage with optic disc and macular edema.
Fluorescein Angiography
Imaging modalities such as fluorescein or indocyanine green angiography was generally used to evaluate retinal vasculature and choroidal vasculature.
Optical coherence tomography (OCT) is a noninvasive imaging technique that uses low-coherence interferometry to produce depth-resolved imaging. A beam of light is used to scan an area of the eye, say the retina or anterior eye, and interferometrical measurements are obtained by interfering with the backscatter or reflectance from ocular structures with the known reference path of traveling light. This modification of classic Michelson interferometry allows for the generation of structural images of anatomy when using OCT.
OCT has become widely adopted in the field of ophthalmology since its introduction in 1991 and has since continually been improved. Until optical coherence tomography angiography (OCT-A), conventional structural OCT images predominantly provided visualization of anatomic changes with low contrast between small blood vessels and tissue within retinal layers.
OCT-A uses the principle of diffractive particle movement of moving red blood cells to determine vessel location through various segments of the eye without the need of any intravascular dyes. OCT-A technology allows for the ability to image flow in the retinal, and choroidal vasculature can be displayed through en face, depth-encoded slabs. These slabs are presented alongside structural OCT B scans. Together, they provide detailed flow imaging of the deep retinal vascular plexus and choriocapillaris, which were not well visualized with previous imaging modalities.
It is important to distinguish the differences between Doppler OCT and OCT-A. Although they both use phase information, Doppler OCT quantifies blood flow in larger vessels and measures total retinal blood flow using phase-shift while OCTA analyzes scatter from a static background tissue to create angiograms.
Types of Hypertensive Retinopathy
Hypertensive retinopathy refers to a spectrum of retinal microvascular signs that typically include:
Mild hypertension. Retinal arteriolar narrowing
More marked hypertension retinopathy. Arteriovenous nicking (avn)
Patients with malignant retinopathy will need urgent antihypertensive management.
Complications of Hypertensive Retinopathy
Medical studies have reported a relationship between hypertensive retinopathy signs and heart disease. The risk of developing congestive heart failure is twice in patients with moderate hypertensive retinopathy, when compared with those without retinopathy. Other studies have shown retinopathy to be strongly associated with coronary artery disease in elderly hypertensives and markers of subclinical or microvascular coronary disease, especially in women with type 1 diabetes.
Hypertensive retinal changes have moderate accuracy in predicting coronary artery disease in patients presenting with acute angina. New studies show that risk for coronary heart disease may be higher in women who were previously deemed ‘low risk’ by traditional risk factors.
Retinopathy was shown to have significant correlation with increased coronary artery calcium scores. Retinal arteriolar narrowing and decreased myocardial blood flow and perfusion reserve are also found to be closely linked. Recent Multi-Ethnic Study of Atherosclerosis study found increased internal carotid intima media thickness to be associated with retinopathy in persons without diabetes, especially among the Whites and Hispanics.
In addition to hypertensive retinopathy, elevated blood pressure is a risk factor for many ocular conditions. These include:
anterior ischaemic optic neuropathy,
retinal vein occlusion,
retinal arteriolar emboli
possibly, age related maculopathy (AMD) and glaucoma.
Tips to Prevent Hypertensive Retinopathy
Evidence is increasing that even mild blood pressure (BP) elevation can have an adverse effect on vascular structure and function in asymptomatic young people. High BP in childhood had been considered a risk factor for hypertension in early adulthood.
The retinal examination is recommended to identify retinal vascular changes in young patients with co-morbid risk factors and BP 90th–94th percentile and in all patients with BP ⩾95th percentile.
The presence of retinopathy may be an indication for more aggressive intervention on associated cardiovascular risk factors and co-morbidities, and has an important practical impact for treatment decisions (for example, antihypertensive and anti-platelet aggregation) and for close follow up.
Overall, the high blood pressure has a significant impact on the retina, and should be prevented at all cost. Hear are the tips how to prevent hypertensive retinopathy:
avoid weight gain. This also applies to prevention of diabetes
exercise daily. Cardio exercise should be in your routine at least twice a week, while walking and jogging should be planned daily
eat balanced diet containing fats, oils and vitamins that build healthy elastic blood vessels
avoid stress which causes significant jumps of blood pressure even in the otherwise healthy people
eye exams are recommended yearly, especially if you have a history of the hypertension and retinopathy in the family
