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HYPERTENSIVE OCULAR DISEASE
FREDDY SITORUSJAKARTA, 25-2-2011
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INTRODUCTION
• Systemic hypertension is a common condition associated with significant morbidity and mortality.
• Hypertension confers cardiovascular risk by causing target-organ damage that includes retinopathy in addition to heart disease, stroke, renal insufficiency and peripheral vascular disease.
• The recognition of hypertensive retinopathy and other ocular disease related to hypertension is important in cardiocerebrovascular risk stratification of hypertensive individuals.
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Direct ocular effect of hypertension
• Hypertensive retinopathy refers to retinal microvascular signs that are related to raised blood pressure.
This sign can be divided into stages.
• Initial response:
Vasospasm and increase in vasomotor tone, which is seen clinically as generalisedretinal- arteriolar narrowing.
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• Chronic arteriosclerosis changes:– Intimal thickening, media wall hyperplasia, and
hyaline degeneration.– manifest as:
• diffuse and focal areas of arteriolar narrowing, • opacification of arteriolar walls ( describe as
silver or copper wiring ), and• compressing of the venules by arteriolar ( term
arteriovenous nipping or nicking)
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• More pronounced high blood pressure:The blood-retinal barriers break down, resulting in– Exudation of blood (haemorrhages)– Lipid ( hard exudates)– Ischaemia of nerve fibre layers (known as cotton-
wool spots).
• Severely high blood pressure raised intra cranial pressure and concomitant optic
nerve ischaemia can lead to disc swelling
(papilloedema) referred as severe or malignant hypertension or
hypertensive optic neuropathy.
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CLASSIFICATION
• Clinically, sign of hypertensive retinopathy are classified into four grades of increasing severity.
• This system is widely used, but early retinopathy grades are difficult to distinguish, also prognostic implications of early retinopathy hypertensive retinopathy grades are not clear.
• Thus a three grade classification system has been proposedMild, Moderate and Severe retinopathy.
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CLASSIFICATION
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Hypertension as a risk factor in ocular disease
• Retinal vein occlusionCharacterised clinically by dilated and tortuous retinal veins and the presence of retinal haemorrhages, cotton-wool spots, and edema of macula and optic disc.Patients typically present with poor visual acuity and a relative afferent papillary defect
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• Retinal artery occlusion• Central retinal artery occlusion present with
a sudden, painless, unilateral loss of vision.
Typically appears as a cherry red spot
• Occlusion of branch retinal artery, could present with visual field defect, an loss of central vision ( can be slight )
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• Ischaemic optic neuropathy.• Is the most frequent acute optic neuropathy
in patient aged over 50.
• Typically present sudden visual loss and optic-disc oedema.
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AAN 2009
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CONCLUSION
• Sign of hypertensive retinopathy are common and correlated with elevated blood pressure.
• This signs predict stroke.• Prompt recognition and accurate diagnosis of
hypertensive retinopathy have important implication for ocular and general health of individual.
• Ophthalmoscopy is an important skills for all neurologist.