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HYPERTENSIVE RETINOPATHY

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 mmHg. 5 TH JOINT NATIONAL COMMITTEE CLASSIFICATION OF BLOOD PRESSURE.

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HYPERTENSIVE RETINOPATHY

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  1. HYPERTENSIVE RETINOPATHY DR AJAY DUDANI DR YASHESH MANIAR

  2. -- MANY CAUSES -- MAINLY ESSENTIAL HYPERTENSION

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

  4. 5TH JOINT NATIONAL COMMITTEE CLASSIFICATION OF BLOOD PRESSURE CATEGORY SYSTOLIC BP DIASTOLIC BP (mmHg) (mmHg) 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

  5. PATHOPHYSIOLOGICAL CHANGES IN HYPERTENSIVE OCULAR DISEASE • HYPERTENSIVE CHOROIDOPATHY • HYPERTENSIVE RETINOPATHY • -- VASOCONSTRICTIVE PHASE • -- SCLEROTIC PHASE • -- EXUDATIVE PHASE • -- COMPLICATIONS OF THE SCLEROTIC PHASE • 3. HYPERTENSIVE OPTIC NEUROPATHY • -- OPTIC DISC EDEMA • -- OPTIC ATROPHY • -- ISCHEMIC OPTIC NEUROPATHY

  6. 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

  7. Grading of arteriolosclerosis

  8. 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

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

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

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

  12. GRADE 3 HTR • 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.

  13. GRADE 4 HTR • All changes of grade 3 • Silver wiring of arterioles • Disc edema

  14. 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

  15. CRVO ... Classic Appearance Mildest Form

  16. CRVO NON ISCHAEMIC ISCHAEMIC

  17. 62/F PR No 17474 CRVO IVTA (elsewhere)

  18. 62/F PR No 17474 CRVO (S/P IVTA) 3 weeks 20/500 Baseline 20/500 2nd IVTA Avastin 2nd Avastin 3 months 20/200 5 months 20/400 8 months 20/100

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

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

  21. Cilioretinal artery occlusion Combined with CRVO

  22. Cilioretinal artery occlusion Combined with anterior ischaemic optic neuropathy

  23. HRVO ...

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

  25. BRVO ...

  26. 45/M PR No 17422 BRVO

  27. 45/M PR No 17422 BRVO Baseline 20/500 STT 3 weeks 20/500 Avastin 6 weeks/8 m 20/80

  28. BRVO

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

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

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

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

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

  34. Ocular associations of hypertension Retinal artery macroaneurysm

  35. Ocular associations of hypertension Anterior ischaemic optic neuropathy

  36. Ocular associations of hypertension Ocular motor nerve palsies

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