I- Overview :
HTA >140/90 mm Hg
All the vascular system undergoes its consequences.
1 Billion & rsquo; individuals worldwide
- extremely common condition
- (25-30)% adult population in industrialized countries .
- (60-70)% after 65 years
Mortality ++ (6% deaths in the World)
II- Reminders anatomical and physiological :
- The retinal vasculature is twofold:
- inner retinal layers
- The ACI opht ACR → → → BR (sup + inf) BR → ( temp+nasal )
- The retinal vessels are terminal arterioles without possibility of substitution.
- Includes Capillary retro: Endoth + Mb.b + Média + adventis ( United / waterproof jct ° nonwindowed)
- At the intersection → AV, l & rsquo; artery and vein are included in the same sleeve & rsquo; weed .
- No & rsquo; innervation (e + på) → local self-regulation
- Retro ext layers + EP
- Choroidal capillaries are formed by capill large diameter big way moléculesOfenêtrés
- + innervation (e + Posting)
Bःhri (Bariérre blood-retinal)
Role important in understanding the pathophysiology of hypertensive retinopathy 2-PART:
- endothelial cells of the retinal vessels : Very tight barrier between plasma and retinal area
- EP (cellules st jointives)
- Mb BREAK (permeable to large molecules)
III- pathophysiology :
local self-regulation :
is the & rsquo; Vx retinal specific ability to react to changes in TA VD) YOU ,TA↓, TA ↑ offset HR
• TA↑ : VC art active
• TA↑↑ : exceeded mechanism , HR internal décompenséeVBHR Out (edema, exsudat, haemorrhage..)
IV- Clinique :
1- Signes d’artériosclérose rétinienne :
- the reflection of the vascular wall changes
- Changes at the intersections arteriovenous
2- Signs of hypertensive retinopathy :
- arterial caliber Changes
- dried exudates
- edema papillary
3- Choroïdopathie hypertensive :
- acute injury
- chronic lesions:
– Spots & rsquo; Elschnig
– Stries de SIEGRIST
The physiological arterial reflection :
the reflection of light at the convex surface of the column
Changes at the arteriovenous crossings is caused by fibrosis of the arteriolar wall which compresses the vein.
4- Signs of hypertensive retinopathy :
A- arterial caliber Changes :
The decreases arterial caliber can be diffuse and widespread, up up & rsquo; one third or one quarter of the normal caliber. They are sometimes located, segmentaires, with a beaded appearance or fusiform. They are particularly good views angiography denies art = 2/3 vein
B- bleeding :
Acceleration HTA process…. TRT urgent and close monitoring +++
Several types :
Splinter perished papillary rupture BHR int…extravasation
round,punctuated, disseminated localized .ischémie (infarct)
C- cotton wool spots: nodules dvsoriques. exudates move
Their manifesto présenace severely impaired, localized, retinal perfusion. These are small superficial nodules, d & rsquo; first grayish, then brilliant white, with fuzzy edges,
D- dried exudates :
They appear as white spots or yellowish, limited well, located at the posterior pole, sitting behind the retinal vessels. Frequently, they take a provision in wheel radius centered on the fovea, constituting a macular star.
E- edema papillary :
In the early stage, only the & rsquo; slit lamp exam may detect : the disc is slightly raised relative to the retinal plane, the veins are dilated, absent spontaneous venous pulse.
IV- choroidopathy hypertensive :
L & rsquo; choroidal involvement is independent of & rsquo; retinal disease. It is found mainly in young patients who develop severe hypertension while their vessels are not flexible and sclerotic (toxémie gravidique, HTA d & rsquo; toxic origin).
On a 2 type lesions :
- acute injury
- chronic lesions(sequelae)
1- Classification de KEITH-WAGNER-BARKER (1939) ++used
- Stade 1 S. moderate retinal arterial narrowing
- Stade 2 S. arteriosclerosis + marked : s.CAV and venous tortuosity
- Stade 3 severe hypertension.
- changing the general art class + haemorrhage
- R et exudates
- Pc vital short-term threat
- Stade 4 HTA maligne
- st 3 + ON
- Pc vital extremely bad
- Benefits : simple
- disadvantages : Confusion of hypertension and arteriosclerosis stages no choroidopathy
2- Classification de kirkendall :
|• Stade 1||diffuse arterial narrowing||Sign of the Cross|
|• Stade II||exudate||Narrowing|
|• Stade III||edema||Préthrombose /|
V- Conclusion :
- Must be distinguished : changes directly related to the & rsquo; elevation of blood pressure, reversible by treatment HTA. chronic changes, irreversible, related to the & rsquo; arteriosclerosis. The treatment is the treatment of & rsquo; hypertension.
- HR remains a recognized event as that & rsquo; d & rsquo reached; a target organ in patients with hypertension.
- It is important that & rsquo; appreciate the response of retinal vessels with anti-hypertension treatments because, if the pathology of these is reversible, it could indicate the reversibility of vascular changes in other organs (heart, rein, brain).
Dr Benlaribi's course – Faculty of Constantine