HYPERTENSIVE RETINOPATHY DR AJAY DUDANI DR YASHESH MANIAR

HYPERTENSIVE RETINOPATHY DR AJAY DUDANI DR YASHESH MANIAR

-- MANY CAUSES -- MAINLY ESSENTIAL HYPERTENSION

SYSTEMIC HYPERTENSION (JNCV 5 TH) STATE OF PERSISTENT ELEVATED BLOOD PRESSURE ABOVE 140/90 mm. Hg.

5 TH JOINT NATIONAL COMMITTEE CLASSIFICATION OF BLOOD PRESSURE CATEGORY SYSTOLIC BP DIASTOLIC BP (mm. Hg) NORMAL <130 <85 HIGH NORMAL 130 -139 85 -89 STAGE 1 (MILD) 140 -159 90 -99 STAGE 2 (MOD. ) 160 -179 100 -109 STAGE 3 (SEVERE) 180 -209 110 -119 STAGE 4(V. SEVERE) >210 >120

PATHOPHYSIOLOGICAL CHANGES IN HYPERTENSIVE OCULAR DISEASE 1. HYPERTENSIVE CHOROIDOPATHY 2. HYPERTENSIVE RETINOPATHY 3. -- VASOCONSTRICTIVE PHASE 4. -- SCLEROTIC PHASE 5. -- EXUDATIVE PHASE 6. -- COMPLICATIONS OF THE SCLEROTIC PHASE 7. 3. HYPERTENSIVE OPTIC NEUROPATHY 8. -- OPTIC DISC EDEMA 9. -- OPTIC ATROPHY 10. -- ISCHEMIC OPTIC NEUROPATHY

OCULAR HYPERTENSION ARTERIOSCLEROSIS GRADE 0 NORMAL GRADE 1 INCREASED LIGHT REFLEX, WITH MILD ARTERIOVENOUS CROSSING DEFECTS GRADE 2 COPPER WIRE APPEARANCE GRADE 3 SILVER WIRE APPEARANCE, WITH MARKED ARTERIO VENOUS CROSSING DEFECTS GRADE 4 FIBROUS CORD

Grading of arteriolosclerosis

OCULAR HYPERTENSION ARTERIOLES A-V RATIO FOCAL SPASM GRADE 0 3: 4 1: 1 GRADE 1 1: 2 1: 1 GRADE 2 1: 3 2: 3 GRADE 3 1: 4 1: 3 +/- C W SPOT GRADE 4 FIBROUS CORD NO DISTAL FLOW +/-ELS SPOT

HYPERTENSIVE RETINOPATHY HEMORRHAGE EXUDATE DISC EDEMA GRADE 0 - - - GRADE 1 - - - GRADE 2 - - - GRADE 3 + + - GRADE 4 + + +

GRADE 1 HTR GENERALIZED ARTERIOLAR ATTENUATION n BROADENING OF ARTERIOLAR LIGHT REFLEX n CONCEALMENT OF VEIN AT A-V CROSSINGS n

GRADE 2 HTR SEVERE GENERALIZED AND FOCAL ARTERIOLAR CONSTRICTION n A-V CROSSING CHANGES (SALUS SIGN) n

GRADE 3 HTR n n n Copper wiring of arterioles Venous banking distal to A-V crossing (bonnet’s sn) Venous tapering on either side of crossing (gunn’s sn) Right angle deflection of veins. Flame shaped hemorrhages cotton wool spots, hard exudates.

GRADE 4 HTR n All changes of grade 3 n Silver wiring of arterioles n Disc edema

Ocular associations of hypertension Retinal vein occlusion • CRVO (Central Retinal Vein Occlusion) • HRVO (Hemi Retinal Vein Occlusion) • BRVO (Branch Retinal Vein Occlusion) Constitutes 69. 5 % of all RVO cases

CRVO. . . Classic Appearance Mildest Form

CRVO NON ISCHAEMIC

62/F PR No 17474 CRVO IVTA (elsewhere)

62/F PR No 17474 CRVO (S/P IVTA) 3 weeks 20/500 Baseline 20/500 2 nd IVTA Avasti n 2 nd Avastin 3 months 20/200 5 months 20/400 8 months

CRVO Hayreh et al – Non – Ischaemic : Due to simple occlusion of retinal venous system n Ischaemic : Due to combined occlusion of the arterial & venous circulation n Green et al – Thrombus formation in the region of lamina cribrosa is the primary event

CRVO Complications / Sequelae. . . q Macular oedema Haemorrhage q Ischaemia stimulates neovascularization in q n n q q Optic disc Retina Angle Iris - Rubeosis may cause Neovascular Glaucoma Rhegmatogenous RD Vascular complications n n Microaneurysyms Optociliary vessels – collaterals between retinal & ciliary vessels

Cilioretinal artery occlusion Combined with CRVO

Cilioretinal artery occlusion Combined with anterior ischaemic optic neuropathy

HRVO. . .

HRVO. . . Superior & Inferior vein do not merge into Central Vein before entering into lamina cribrosa n Like CRVO, only superior or inferior half involved n Types n - n 2/3 rd : 1/3 rd : Venous stasis Haemorrhagic Rest Rx or management same as CRVO

BRVO. . .

45/M PR No 17422 BRVO

45/M PR No 17422 BRVO Baseline 20/500 3 weeks 20/500 6 weeks/8 m 20/80 STT Avastin

BRVO

BRVO. . . n Portion of retina involved n Mostly temporal - 62% Superotemporal - 38% Inferotemporal n Nasal – uncommon & asymptomatic n Occurs exclusively at arterial overcrossing at AV intersection by a thrombus

Investigations in RVO. . . n Hb/CBC/ESR/Platelet count n BSL – Fasting/PP n BP n Sr. Lipid Profile n IOP Measurement n FFA n ANA/Anti-ds DNA n VDRL/FTA-Abs n LE Cell

In Young. . . n Protein C levels n Protein S levels n Platelet Analysis n Sr. & Urine for Homocysteine levels

Others. . . n Hb Electrophoresis n PT / PTT n Anti-Phospholipid antibody n Complete Cardiovascular evaluation

Traditional Rx Options. . . n To treat the associated systemic diseases (Medical Rx) n To treat the ocular complications (Laser or Sx) - CRVO Study Group - BRVO Study Group

Ocular associations of hypertension Retinal artery macroaneurysm

Ocular associations of hypertension Anterior ischaemic optic neuropathy

Ocular associations of hypertension Ocular motor nerve palsies