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Hypertensive retinopathy is retinal vascular damage caused by hypertension. Symptoms develop late. Funduscopic examination shows arteriolar constriction, arteriovenous nicking, vascular wall changes, flame-shaped hemorrhages, cotton-wool spots, yellow hard exudates, and papilledema. Treatment is directed at controlling BP and, when vision loss occurs, treating the retina.
Pathophysiology
Acute BP elevation typically causes reversible vasoconstriction in retinal blood vessels, and hypertensive crisis may cause papilledema. More prolonged or severe hypertension leads to exudative vascular changes, a consequence of endothelial damage and necrosis. Other changes (eg, arteriole wall thickening) typically require years of elevated BP to develop. Smoking compounds the adverse effects of hypertension on the retina.
Hypertension is a major risk factor for other retinal disorders (eg, retinal artery or vein occlusion, diabetic retinopathy). Also, hypertension combined with diabetes greatly increases risk of vision loss. Patients with hypertensive retinopathy are at high risk of hypertensive damage to other end organs.
Symptoms and Signs
Symptoms usually do not develop until late in the disease.
In the early stages, funduscopy identifies arteriolar constriction, with a decrease in the ratio of the width of the retinal arterioles to the retinal venules.
Chronic, poorly controlled hypertension causes the following:
Sometimes total vascular occlusion occurs. Arteriovenous nicking is a major predisposing factor to the development of a branch retinal vein occlusion.
If acute disease is severe, the following can develop:
Yellow hard exudates represent intraretinal lipid deposition from leaking retinal vessels. These exudates can form a star-shaped lesion in the macula, particularly when hypertension is severe. In severe hypertension, the optic disk becomes congested and edematous (papilledema indicating hypertensive crisis).
Diagnosis
Diagnosis is by history (duration and severity of hypertension) and funduscopy.
Treatment
Hypertensive retinopathy is managed primarily by controlling hypertension. Other vision-threatening conditions should also be aggressively controlled. If vision loss occurs, treatment of the retinal edema with laser or with intravitreal injection of corticosteroids or anti–vascular endothelial growth factor (VEGF) drugs may be useful.
Last full review/revision December 2008 by Sunir J. Garg, MD, FACS
Content last modified December 2008
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