Hypertensive Retinopathy and Sclerotic Changes

Hypertensive Retinopathy and Sclerotic Changes

Definition

Arterial changes in hypertension are primarily caused by vasospasm; in arterio-sclerosis they are the result of thickening of the wall of the arteriole.

Epidemiology: 

Arterial hypertension in particular figures prominently inclinical 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-retinabarrier or obliteration of capillaries. This results in intraretinal bleeding, cot-ton-wool spots, retinal edema, or swelling of the optic disk.

Symptoms: 

Patients with high blood pressure frequently suffer from head-ache 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 thefundus are diagnosed by ophthalmoscopy, preferably with the pupil dilated (Tables 12.3 and 12.4). Changes in the retinal vasculature are frequent find-ings; 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 excludeother 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 under-lying disorder.

Treatment: 

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

Prophylaxis: 

Regular blood pressure monitoring and ophthalmoscopicexamination of the fundus are required to minimize the risk of complications (see below).

Clinical course and complications: 

Sequelae of arteriosclerotic and hyper-tensive vascular changes include retinal artery and vein occlusion and the for-mation of macroaneurysms that can lead to vitreous hemorrhage. In the pres-ence 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.