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A Review of Hypertensive Retinopathy and Chorioretinopathy

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A Review of Hypertensive Retinopathy and Chorioretinopathy Clinical Optometry Dovepress open access to scientific and medical research Open Access Full Text Article REVIEW A Review of Hypertensive Retinopathy and Chorioretinopathy This article was published in the following Dove Press journal: Clinical Optometry Mai Tsukikawa Abstract: Hypertensive retinopathy and choroidopathy have important short- and long-term Andrew W Stacey implications on patients’ overall health and mortality. Eye care professionals should be familiar with the severity staging of these entities and be able to readily recognize and Department of Ophthalmology, University of Washington, Seattle, WA refer patients who are in need of systemic blood pressure control. This paper will review the 98104, USA diagnosis, staging, treatment, and long-term implications for vision and mortality of patients with hypertensive retinopathy and choroidopathy. Keywords: hypertensive retinopathy, hypertensive choroidopathy, hypertensive chorioretinopathy Introduction Hypertension is a risk factor for many systemic conditions that cause serious morbidity and mortality. The World Health Organization defines hypertension as a systolic blood pressure of greater than 140 mmHg and/or a diastolic blood pressure of greater than 90 mmHg, with an estimated 1.13 billion people worldwide affected by this condition.1 Hypertension can affect the eyes in several ways, including the development of retinopathy, choroidopathy, and optic neuropathy. It is also a risk factor for other vision- threatening eye conditions including branch retinal artery occlusion (BRAO), central retinal artery occlusion (CRAO), branch retinal vein occlusion (BRVO), central retinal vein occlusion (CRVO), retinal artery macroaneurysms, and non-arteritic anterior ischemic optic neuropathy (NAION). Hypertension increases the risk for the develop- ment and progression of diabetic retinopathy, glaucoma, and age-related macular degeneration.2 Hypertension is also a risk factor for the development of suprachoroidal hemorrhage during ophthalmic surgery. The eye is the only organ in the body where the vascular changes due to systemic hypertension can be observed in vivo. The most common ocular presentation of hypertension is hypertensive retinopathy. There are several grading systems for hyper- tensive retinopathy that have been proposed to classify its severity. The most widely cited is the Keith-Wagener-Barker classification proposed in 1939 (Table 1).3 Wong and Mitchell recently proposed a simplified grading system in 2004 (Table 2).4 Hypertensive retinopathy can be the presenting sign of hypertensive emergency, an Correspondence: Mai Tsukikawa acute, life-threatening condition resulting from markedly increased blood pressure that Department of Ophthalmology, leads to acute end-organ damage. Elevated blood pressure with evidence of moderate University of Washington, 325 Ninth Ave, Box 356421, Seattle, WA 98104, USA hypertensive retinopathy has been referred to as “accelerated hypertension,” while Tel +1 206-221-7921 elevated blood pressure with evidence of severe hypertensive retinopathy, including Fax +1 206-685-7055 Email [email protected] optic disc swelling, has been referred to as “malignant hypertension.” submit your manuscript | www.dovepress.com Clinical Optometry 2020:12 67–73 67 DovePress © 2020 Tsukikawa and Stacey. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress. – http://doi.org/10.2147/OPTO.S183492 com/terms.php and incorporate the Creative Commons Attribution Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Tsukikawa and Stacey Dovepress Table 1 Keith-Wagener-Barker Classification of Hypertensive venules where they cross, termed arteriovenous (AV) cross- Retinopathy ing or nicking (Figure 1A). Microaneurysms may form. Grade 1 Mild generalized retinal arteriolar narrowing Severe hypertension creates focal areas of ischemia of the Grade 2 Definite focal narrowing and arteriovenous nipping retinal nerve fiber layer, seen as cotton-wool spots. Grade 3 Signs of grade 2 retinopathy plus retinal hemorrhages, Breakdown of the blood-retina barrier causes exudation of exudates and cotton wool spots blood as retinal hemorrhages or exudation of lipids as hard Grade 4 Severe grade 3 retinopathy plus papilledema exudates (Figure 1B). Very severe hypertension can lead to increased intracranial pressure, causing optic nerve ischemia Table 2 Wong and Mitchell Classification of Hypertensive and optic disc swelling (Figure 1C).4,5 Retinopathy Mild 1 or more of the following signs: generalized arteriolar Pathophysiology of Hypertensive narrowing, focal arteriolar narrowing, arteriovenous nicking, arteriolar wall opacity Chorioretinopathy Hypertensive choroidopathy, usually seen in combination with Moderate 1 or more of the following signs: retinal hemorrhage (blot-, dot-, or flame-shaped), microaneurysm, cotton hypertensive retinopathy and termed hypertensive chorioreti- wool spot, hard exudates nopathy, is often seen in younger patients who have acute elevations in blood pressure. Hypertensive choroidopathy is Severe Moderate retinopathy plus optic disc swelling characterized by fibrinoid necrosis of choroidal arterioles, with resultant non-perfusion of the overlying choriocapillaris and Pathophysiology of Hypertensive focal ischemic damage to the retinal pigment epithelium 6 Retinopathy (RPE). Areas of focal ischemia appear as yellowish lesions at the level of the RPE, called Elschnig spots. Over time, these The vascular changes associated with systemic elevated become irregularly pigmented with a depigmented halo. blood pressure are visible in the retina as hypertensive reti- Ischemia along choroidal lobules appear as linear hyperpig- nopathy. Early findings include generalized narrowing of the mented streaks along the course of underlying choroidal retinal arteriolar vessels due to vasospasm and increased arteries, called Siegrist streaks. Macular edema is often pre- vascular tone. Chronic hypertension leads to structural sent. When blood pressure is severely elevated, global chor- changes in the vessel wall such as intimal thickening and oidal dysfunction affects the pumping capacity of the RPE, hyaline degeneration. These manifest as focal or diffuse areas which leads to serous retinal or RPE detachments. 2,4 of vessel wall opacification, called copper or silver wiring. Hypertensive chorioretinopathy is thought to happen Thickening of the arterioles leads to compression of the more commonly in younger patients due to the elasticity Figure 1 Grades of hypertensive retinopathy. (A) Mild hypertensive retinopathy (in an eye with an unrelated chorioretinal lesion) with arteriolar narrowing (white arrow), copper wiring (black star), and AV nicking (black arrow). (B) Moderate hypertensive retinopathy with features of mild hypertensive retinopathy as well as cotton wool spots (yellow arrow) and intraretinal hemorrhages (red arrow). (C) Severe hypertensive retinopathy with features of moderate hypertensive retinopathy and optic disc swelling (white star). 68 submit your manuscript | www.dovepress.com Clinical Optometry 2020:12 DovePress Dovepress Tsukikawa and Stacey of their blood vessels. In response to acute systemic hyper- cardiovascular risk factors, such as age, gender, smoking sta- tension, the flexible choroidal arterioles initially undergo tus, systolic blood pressure, and major adverse cardiac events.8 constriction, leading to non-perfusion of the choriocapil- Spectral domain optical coherence tomography (SD-OCT) laris. In addition, the choroidal arteries supply the chorio- may demonstrate thinning of the inner retina and focal attenua- capillaris at right angles, so the systemic blood pressure is tion of the ellipsoid zone in areas of the Elschnig spots. transmitted more directly to the choriocapillaris.6 Findings such as pigmentary epithelial detachments or serous retinal detachments may be visualized on SD-OCT, and their Diagnosis of Hypertensive evolution or resolution may be monitored (Figure 3). Swept Chorioretinopathy source optical coherence tomography (SS-OCT) allows dee- per penetration into the tissues; one study reported an increase Hypertensive chorioretinopathy is diagnosed based on its in choroidal thickness in the acute phase of hypertensive clinical appearance on funduscopic exam as well as coex- choroidopathy.9 SS-OCT angiography may reveal a moth- istent hypertension. The funduscopic exam would show the findings described above, with hypertensive choriore- eaten appearance of the choriocapillaris, signifying areas of 10 tinopathy demonstrating the findings of hypertensive reti- choroidal nonperfusion. Reperfusion of the choriocapillaris 11 nopathy plus choroidal findings. may be seen after antihypertensive treatment is initiated. fl fl There are many imaging modalities that are helpful for the Fundus auto uorescence demonstrates hypoauto uores- 12 fl diagnosis and management of hypertensive chorioretinopathy. cence of Elschnig spots. There may also be hypoauto uor- Retinal imaging, in particular wide-field color fundus photo- escence due to intraretinal hemorrhages and cotton wool spots graphy, is useful to document
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