Title: Hypertensive Retinopathy
Author: J. Erik Kulenkamp, MS4, University of Chicago
Hypertension is a systemic disease characterized by elevated blood pressure, or blood pressure greater than 140/90 mmHg, and is seen in 73 million US adults. Broadly, there exist two categories of hypertension: essential and secondary. Essential or primary hypertension is far more common in the general population and is not caused by another illness. Secondary hypertension is a manifestation of another medical condition such as renal artery stenosis, obstructive sleep apnea, preeclampsia/eclampsia, Cushing’s syndrome, pheochromocytoma, coarctation of the aorta, and many others. Regardless of etiology, acutely or chronically elevated blood pressures can damage the eye, and in particular, the retina.
Hypertensive retinopathy is the result of changes to the retinal vasculature in high blood pressure states. Initially, arteriolar tone is increased due to autoregulation in the body’s attempt to reduce blood flow, causing the arterioles to narrow. Over time, involved vessels can become sclerotic, with thickened intima and media layers. Eventually, the blood-retina barrier can be disrupted, resulting in exudates and retinal ischemia or hemorrhage.
The signs and symptoms of hypertensive retinopathy vary depending on whether the elevation in blood pressure is chronic or acute. Patients with chronic hypertension are often asymptomatic but can experience decreased vision. Signs include arteriolar narrowing (with decreased size relative to corresponding venules), arteriovenous (AV) nicking (where arterioles cross venules), arteriolar sclerosis (with the appearance of copper wiring), flame hemorrhages, and cotton wool spots. Many of these findings are visible in Figure 1. Patients with acute or malignant hypertension can present with decreased vision and headaches, accompanied by significantly elevated blood pressure. However, they can also be asymptomatic. On fundoscopic exam, flame and dot blot hemorrhages, hard exudates, cotton wool spots, retinal edema, and papilledema (present in severe hypertensive retinopathy) can be seen. Hypertensive retinopathy sometimes leads to retinal vein occlusions. Less often, it precipitates serous retinal detachments or vitreous hemorrhages.
Diabetic retinopathy can present with similar findings and should be on the differential, especially in a patient with known diabetes. However, it usually lacks classic signs of AV nicking and arteriolar narrowing. Retinal vein occlusions can share overlapping features as well, although they’re more often unilateral. If hypertensive retinopathy is suspected, review of systems should evaluate for symptoms of cardiovascular complications and other end-organ damage. Providers should check blood pressure and auscultate for bruits. In addition, they should either perform or refer for dilated fundoscopic examination (emergently if signs and symptoms of a hypertensive crisis are present). Malignant hypertension should be managed acutely in the emergency department. The treatment for hypertensive retinopathy involves controlling blood pressure through the administration of antihypertensive agents such as diuretics, angiotensin converting enzyme (ACE) inhibitors, Angiotensin II receptor blockers (ARB’s), calcium channel blockers, vasodilators, and alpha-adrenergic blockers.
Figure 1: Classic findings in Hypertensive Retinopathy
Color Fundus Photo of Right Eye, Taken 5/29/2015 at JMEC
Pertinent History and Physical: 40 year old male presenting with blurry vision of several weeks duration and severely elevated blood pressure on exam. After fundoscopy, he was transferred from clinic to the emergency department.Figure 2: Hypertensive Retinopathy in Same Patient After Antihypertensive Treatment
Color Fundus Photo of Right Eye, Taken 8/31/15 at JMEC
Pertinent History and Physical: 40 year old male featured in Figure 1 with resolving blurry vision.References1–7:
- Wong TY, Mitchell P. Hypertensive Retinopathy. N Engl J Med. 2004;351(22):2310-2317. doi:10.1056/NEJMra032865.
- Bagheri Nika, Wajda Brynn N, Calvo Charles M, Durrani Alia K, Friedberg Mark A, Rapuano Christopher J. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Seventh edition. Philadelphia: LWW; 2016.
- Grosso A, Veglio F, Porta M, Grignolo FM, Wong TY. Hypertensive retinopathy revisited: some answers, more questions. Br J Ophthalmol. 2005;89(12):1646-1654. doi:10.1136/bjo.2005.072546.
- Henderson AD, Biousse V, Newman NJ, Lamirel C, Wright DW, Bruce BB. Grade III or Grade IV Hypertensive Retinopathy with Severely Elevated Blood Pressure. West J Emerg Med. 2012;13(6):529-534. doi:10.5811/westjem.2011.10.6755.
- James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.
- Haas AR, Marik PE. CRITICAL CARE ISSUES FOR THE NEPHROLOGIST: Current Diagnosis and Management of Hypertensive Emergency. Semin Dial. 2006;19(6):502-512. doi:10.1111/j.1525-139X.2006.00213.x.
- Ophthalmology AA of. 2017-2018 Basic and Clinical Science Course. (MD HJI, ed.). S.l.: American Academy of Ophthalmology; 2017.