Ophthalmic manifestations of L’HTA and the’arteriosclerosis

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I- Overview :

HTA >140/90 mm Hg

All the vascular system undergoes its consequences.

1 billion’individuals in the world

  • 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:

ACR :

  • 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’artery and vein are encompassed in the same sleeve d’adventice .
  • No’innervation (e + på) → local self-regulation

Choriocapillaire :

  • 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:

Internal :

  • endothelial cells of the retinal vessels : Very tight barrier between plasma and retinal area

external :

  • EP (cellules st jointives)
  • Mb BREAK (permeable to large molecules)

III- pathophysiology :

local self-regulation :

is’specific ability of retinal Vx to respond 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- Signs of’retinal arteriosclerosis :

  1. the reflection of the vascular wall changes
  2. Changes at the intersections arteriovenous

2- Signs of hypertensive retinopathy :

  1. arterial caliber Changes
  2. bleeding
  3. nodules
  4. dried exudates
  5. edema papillary

3- Choroïdopathie hypertensive :

  1. acute injury
  2. chronic lesions:

– Stains’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 to’one third or one quarter of the normal size. 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 :

– superficial

Splinter perished papillary rupture BHR int…extravasation

– deep

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’initially 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 l’Biomicroscope examination can detect it : the disc is slightly raised relative to the retinal plane, the veins are dilated, absent spontaneous venous pulse.

IV- choroidopathy hypertensive :

L’choroidal involvement is independent of’retinal damage. It is found mainly in young patients who develop severe hypertension while their vessels are not flexible and sclerotic (toxémie gravidique, HTA d’toxic origin).

On a 2 type lesions :

  1. acute injury
  2. chronic lesions(sequelae)

CLASSIFICATIONS :

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 :

stadiums HTA Arteriosclerosis
• Stade 1 diffuse arterial narrowing Sign of the Cross
• Stade II exudate Narrowing
woolly arterial located
hemorrhage
• Stade III edema Préthrombose /
papillary vascular thrombosis
engainement arterial
Recho CREPE

V- Conclusion :

  • Must be distinguished : modifications directly related to the’elevation of blood pressure, reversible by treatment HTA. chronic changes, irreversible, related to’arteriosclerosis. The treatment lies in the treatment of the’HTA.
  • HR remains a recognized manifestation as’reached d’a target organ in hypertensive patients.
  • It is important to’assess the response of retinal vessels to 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

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