Hypertensive Retinopathy

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Last updated: November 13, 2024Bookmark

Table Of Contents

Overview
Acute Hypertensive Retinopathy
Chronic Hypertensive Retinopathy

Overview

Hypertensive Retinopathy is a disease of the retinal and choroidal vasculature due to severe acute or chronic hypertension.

Chronic hypertensive retinopathy is more common and is predominantly seen in older patients.

Disease Process	Cause	Patients
Acute hypertensive retinopathy	Sudden, severe hypertension (commonly secondary hypertension)	Patients of any age
Chronic hypertensive retinopathy	Longstanding hypertension and atherosclerosis. Atherosclerosis causes retinal arterioles to expand and compress venules leading to branch retinal vein occlusion.	Older patients

Regulation of the retinal and choroidal vasculature
- The retinal vasculature is autoregulated. It loses it autoregulation as diastolic blood pressure exceeds 110-115 mmHg.
- The choroidal vasculature is regulated by the sympathetic nervous system

Acute Hypertensive Retinopathy

Acute hypertensive retinopathy is seen in patients with hypertensive crisis (BP > 200/110). Elevated blood pressure damages the retinal and choroidal blood vessels through fibrinoid necrosis and ischemic necrosis.

Ophthalmoscopic findings
- Cotton wool spots: Ischemia to nerve fibers
- Uniform narrowing of arterioles and Tortuosity: uniform narrowing since all vessels are affected (unlike in chronic hypertensive retinopathy)
- Flame hemorrhages and dot blot hemorrhages: Necrosis and bleeding
- Papilledema (disc edema): Leakage from the arterioles supplying the optic disk. The optic disk appears confluent with the rest of the retina.
- Elsching spots: Damage to the retinal pigment epithelium
Treatment
- Manage the hypertensive crisis.
- Avoid a steep reduction in BP as it can worsen damage
Complications
- Retinal detachment: Due to damage and exudates in the choroid and Retinal pigment epithelium. Causes traction/exudative retinal detachment. Signs and symptoms – Acute change in vision, photopsia, floaters
- Optic neuropathy: ischemia of the optic nerve head due to vasoconstriction. Signs and symptoms – blurred disk margin, papilledema, flame hemorrhages

Fundoscopy findings in Hypertensive Retinopathy

Chronic Hypertensive Retinopathy

Chronic hypertensive retinopathy is an end-organ manifestation of hypertension. Chronic hypertension accelerates the development of atherosclerosis. Atherosclerosis decreases the radius of arterioles. These arterioles expand to down-regulate resistance to flow and as the expand they compress the venules. Advanced forms of chronic hypertensive retinopathy causes a loss in visual acuity.

Risk factors for chronic hypertensive retinopathy
- Age
- Black race
- FHx
- Smoking
- Obesity
- Stress
- Sedentary lifestyle
- Excessive alcohol consumption
What additional risks do patients with chronic hypertensive retinopathy have?
- Stroke (7x)
- Myocardial infarction (4x)
- Coronary artery disease (3x)
- Peripheral artery disease (2x)
Ophthalmoscopic findings
- Focal to Uniform narrowing of the arterioles
- AV nicking and AV crossing: due to arterioles compressing the venules. This is a hallmark finding of chronic hypertensive retinopathy
- Flame hemorrhage and dot-blot hemorrhage
- Copper-wiring and silver wiring: narrowing of the vascular lumen due to atherosclerosis
- Macula star: exudation around the macula in advanced chronic hypertensive retinopathy
Treatment
- Manage the underlying hypertension
Complications
- Branch retinal vein occlusion/ Central retinal vein occlusion: due to AV nicking/occlusion
- Retinal detachment: due to vascular fibrosis (tractional RD)
- Optic nerve atrophy: due to chronic optic disk swelling. Leads to decreased visual acuity.

AV crossing, AV nicking, copper wiring and silver wiring seen in chronic hypertensive retinopathy. Source- American Academy of Opthalmology

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Calculator ›

Overview

Acute Hypertensive Retinopathy

Chronic Hypertensive Retinopathy

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