H35.031-033 Hypertensive Retinopathy

Retinal hemorrhages indicate
Stage 3 hypertensive retinopathy

ICD-10 Diagnosis Codes:

H35.031–Hypertensive retinopathy, right eye
H35.032–Hypertensive retinopathy, left eye
H35.033–Hypertensive retinopathy, bilateral

Title
Hypertensive Retinopathy

Category
Other Retinal Disorders

Description
Hypertensive retinopathy is damage to the retina from high blood pressure.

DEFINITION

Hypertension produces many ophthalmic manifestations. Because of the structural differences between the retina, the choroid, and the optic nerve, the vascular response to systemic hypertension varies according to the anatomic region.

Retinal response to chronic hypertension:

Arteriolosclerosis (generalized narrowing of the retinal blood vessels)
Copper wiring and silver wiring of retinal arterioles secondary to arteriosclerosis
Arteriovenous nicking secondary to arteriosclerosis
Retinal hemorrhages
Nerve fiber layer fallout
Increased tortuosity of retinal blood vessels
Remodeling of blood vessels due to capillary nonperfusion

Choroidal response to chronic hypertension:

Areas of the retinal pigment epithelium (RPE) atrophy and form focal white lesions
Choroidal ischemia
Serous retinal detachment secondary to retinal pigment epithelial necrosis

NATURAL HISTORY

Hypertensive retinopathy is a risk factor for systemic morbidity and mortality. The Atherosclerosis Risk in Communities (ARIC) study demonstrated that hypertensive retinopathy is strongly associated with elevated blood pressure, but variable in its association with elevated cholesterol and other risk factors for atherosclerosis.

Mild hypertensive retinopathy (focal arteriolar narrowing and arteriovenous nicking) are weakly associated with systemic vascular disease. More severe presentations (microaneurysms, hemorrhages and cotton-wool spots) have astrong association with subclinical cerebrovascular disease, stroke, congestive heart failure and cardiovascular mortality.

Structural Damage to the Eye

Retinal hemorrhages
Optic neuropathies
Cranial neuropathies
Subconjunctival hemorrhages
Arteriovenous nicking
Cotton-wool spots
Retinal and macular edema
Lipid deposits
Macular star

Functional Damage to the Eye and Visual System

No visual, physical or ocular symptoms
Headaches
Blurred vision

DIAGNOSTIC EVALUATION

The main goal of the diagnostic evaluation in a patient with hypertensive retinopathy is to accomplish the following:

Determine the presence or absence of hypertensive retinopathy
Classify the hypertensive retinopathy
Identify and exclude differential diagnosis
Determine if the retinopathy is clinically significant and/or vision threatening
Prescribe a treatment program

Patient History

The severity of the symptoms or signs is varied and depends on severity of the retinal/choroidal changes. Patients can present with the following abnormal symptoms:

Blurred vision (sudden or gradual)
Distorted vision (sudden or gradual)
Difficulty driving at night
Floaters or dark spots in their field of view

Clinical Appearance of the Retina

The retinal changes associated with hypertensive retinopathy include the following:

Hemorrhages
Microaneurysms
Cotton-wool spots
Edema
Ischemia
Venous beading
Intraretinal microvascular abnormalities
Retinal thickening
Increased retinal vessel tortuosity

Grade 3 Hypertensive Retinopathy

Cotton-wool spots are fluffy white lesions found in the retinal nerve fiber layer
Lesions occur secondary to ischemia
Most commonly found at the posterior pole
Usually lasts approximately 3-6 weeks before fading away
Fluorescein angiography reveals hypofluorescence secondary to vascular nonperfusion and capillary dropout

DIAGNOSTIC TESTS

Fundus Photography

To document the progress or lack of progress of hypertensive retinopathy
To document the delivery of medical treatment
To document the response to treatment
To help plan a treatment program
Fundus autofluorescence imaging can be used to detect structural abnormalities and predict functional deficits

Retinal Hemorrhage Secondary to Hypertensive Retinopathy — Initial Visit

67-year-old black female with hypertension
Optic disc hemorrhage discovered on routine ophthalmoscopy
Hemorrhage appears as a flame-shaped or splinter-like lesion at the superior border of the optic disc

Optic Disc Hemorrhage May Be Associated With The Following:

Hypertension
Diabetes
Normal-tension glaucoma
Aspirin use

Same Patient As Above — 8 Days Later

Retinal hemorrhage is absorbed within 8 days
No permanent structural damage to the optic nerve or retina
No functional loss of vision

Optic Disc Hemorrhage — Pathophysiology

Vasculopathy associated with systemic hypertension and diabetes can cause microinfarctions and ischemic changes in optic disc vessels, making these vessels vulnerable to mechanical rupture

Retinal Scanning Laser

To measure the microscopic anatomy of the retina and vitreoretinal interface
To measure the effectiveness of therapy
To help in determining the need for ongoing therapy
To determine the safety of cessation of therapy

Visual Field Examination

Used to assess visual function and determine the size of any associated visual field defects
Visual field may be affected depending on the size and location of retinal hemorrhaging the extent of the visual field defect depends on size of macular edema

B-Scan Ophthalmic Ultrasound

A two-dimensional ultrasonic scanning procedure used to produce cross-sectional images of the eye and orbit
B-scan ophthalmic ultrasound can be used to assess internal structures of the eye when a vitreous hemorrhage prevents proper visualization and examination of the retina
The test results are used to determine whether the retina is attached or detached

CLASSIFICATION

In 1953, Scheie developed a staging system for hypertensive retinopathy ranging from normal to the most severe retinal changes.

Grade 0 Hypertensive Retinopathy

Patient diagnosed with hypertension
No visible retinal vascular abnormalities

Grade 1 Hypertensive Retinopathy

Diffuse retinal arteriolar narrowing
Blood vessel caliber is uniform, with no focal constriction


		Grade 2 Hypertensive Retinopathy Narrowing of the retinal arterioles Blood vessel caliber is not uniform (arteriovenous nicking)

		Grade 3 Hypertensive Retinopathy Focal and diffuse arteriolar narrowing Retinal hemorrhages may be present Cotton-wool spots may be present

Grade 4 Hypertensive Retinopathy

All of the previously listed retinal abnormalities may be present in addition to the following:

Retinal and macular edema
Hard exudates
Optic disc edema

DIFFERENTIAL DIAGNOSES

Diabetic Retinopathy

The abnormal clinical findings are very similar to moderate hypertensive retinopathy (e.g., microaneurysms, hemorrahges and cotton-wool spots)
Hard exudates are usually not found in hypertensive retinopathy but are common in diabetic retinopathy


		Optic Disc Hemorrhage Secondary to Vitreopapillary Detachment Hemorrhage is actually of the optic disc surface Bleeding is from mechanical trauma as opposed to a vascular problems

		Retinal Venous Obstruction Central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO) can produce retinal hemorrhages similar in appearance, however the onset of CRVO and BRVO are sudden versus hypertensive retinopathy’s clinical signs which usually develop over time Decreased visual acuity is a common finding in vein occlusions but not hypertensive retnopathy

		Retinal Telangectasia Pathologically dilated blood vessels leak fluid into the retinal tissue Exudative formation secondary to fluid retention is similar in appearance to the exudates found in diabetic retinopathy, but not hypertensive retinopathy Exudate formation is seen in severe, long-standing cases and there would be other clinical signs of hypertensive retinopathy in addition to the presence of the exudates

		Leukemia Ocular manifestations of leukemia can produce the following retinal vessel changes microaneurysms blood vessel dilation neovacularization cotton wool spots

Ocular Manifestations of HIV

Acute retinal necrosis as seen in an HIV-positive patient
Similar to hypertensive retinopathy cotton-wool spots

TREATMENT OPTIONS

Treatment for hypertensive retinopathy involves evaluation of secondary causes and appropriate medical co-management with the patient’s primary care doctor. Lowering blood pressure would be the primary course of action in reducing the risk of further retinal changes.

Several studies report that hypertensive retinopathy may regress over a 6-12 month period with control of elevated blood pressure.

Patients with mild clinical signs can usually be managed with with routine care and the target blood pressure range should be based on established guidelines
Patients with moderate clinical signs may benefit from additional assessment of vascular risk (e.g., measurement of cholesterol levels) and appropriate risk reduction therapy
Patients with severe clinical signs need urgent anti-hypertensive treatment (e.g., intravenous medication)

The following systemic medications can be used to lower blood pressure:

Calcium channel blockers
Diuretics
Angiotensin receptor blockers
Angiotensin converting enzyme (ACE) inhibitors
Anti-andrenergics
Vasoconstrictors
Renin inhibitors

And, of course, exercise and proper diet have long been a means of improving cardiovascular health.

REFERENCES

1. Suhr C. How hypertension and high cholesterol harm the eye. RevOptom. 2014 April 15; 151(4): 34-41. http://www.revoptom.com/content/c/47790/. Last accessed August 10, 2014.
2. O’Toole L. Hypertensive Retinopathy. Optometry Today. http://www.optometry.co.uk/uploads/exams/articles/cet_02_09_2011_otoole.pdf. Last accessed July 9, 2014.
3. Theng K. Ophthalmologic Manifestations of Hypertension. Emedicine/Medscape. 2014 Mar 21. http://emedicine.medscape.com/article/1201779-overview. Last accessed July 9, 2014.
4. Hypertensive Retinopathy. Handbook of Ocular Disease Management. http://cms.revoptom.com/handbook/sect41b.htm. Last accessed July 9, 2014.
5. Wong T. McIntosh R. Hypertensive Retinopathy Signs as Risk Indicators of Cardiovascular Morbidity and Mortality. Br Med Bull (2005). http://bmb.oxfordjournals.org/content/73-74/1/57.full. Last accessed August 10, 2014.
6. Bourke K. Patel M. Prisant M. Marcus D. Journal of Clinical Hypertension. 2004 August; 6(8): 471-472. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-6175.2004.3749.x/pdf. Last accessed August 10, 2014.
7. Copeland R. Ocular Manifestations of HIV Infectrion. Emedicine/Medscape. 2013 Oct 18. http://emedicine.medscape.com/article/1216172-overview#aw2aab6b5. Last accessed August 10, 2014.