Author: Ameen Marashi, MD

History  

A detailed hypertension disease history documented, including severity and duration, along with medication and compliance.  

It is essential to collect symptoms such as headaches, difficulties of breathing (dyspnea or orthopnea), or chest pain documented along with the history of central, peripheral, heart failure, stroke, or transient ischemic attack ^[1].   

Medical history of diabetes mellitus along with cardiovascular diseases, sleep apnea, coagulopathies, thrombotic disorders, etc.. documented.   

Ocular history obtained, such as ocular pain, visual loss includes metamorphopsia, location, and duration, associated with ocular diseases such as glaucoma cataract, amblyopia, diabetic retinopathy, etc..   

History documented previous ocular treatments such as topical medications, surgical interventions (cataract, refractive, etc.) laser, injections (intravitreal, sub-tenon, etc.) and medication such as Anti-VEGF, steroids, or other.   

Ocular Examination  

A list of ocular examination should set   

1) Best-corrected visual acuity (BCVA), this is an essential step which can be performed by a trained optometrist or certified ophthalmologist to document the visual impairment. And this will help in the follow-up visits to assess the efficacy of the treatment, especially in cases of macroaneurysm.   

2) A slit-lamp examination done with a thorough exam of clarity and regularity of the cornea and to rule out conjunctival abnormality such injection of conjunctival vessels should be documented. And any other inflammations of the conjunctiva or eyelids documented, along with the Meticulous iris exam to rule out neovascularization and crystalline lens exam to rule out cataract or intraocular lens (IOL) to document the position and clarity of the posterior capsule. 

3) Intra Ocular Pressure (IOP) documentation is essential as high IOP is associated with a patient with glaucoma history.  

Note when high IOP spotted a corrected IOP documented after central corneal thickness measurement.  

Gonioscopy can be scheduled after the dilated fundus exam (if not done in the initial ocular examination) when ischemic changes are confirmed.  

4) Bilateral dilated fundus exam is an essential and detailed examination of the optic disc, macula, posterior pole, a mid-peripheral and peripheral retinal exam with specialized indirect wide-field lenses using slit-lamp biomicroscopy or indirect ophthalmoscopy:  

• Macular edema is secondary to exudative hypertensive retinopathy or macroaneuysm clinically and by using OCT.   

• Vasoconstrictive changes such as general arterial narrowing, sclerotic changes such as silver, copper wiring, nicking, or nipping, are signs of prolonged increased hypertension. Exudative changes spotted such as retinal hemorrhages, hard Exudates, and cotton wool spots; however, in cases of macroaneurysm, a focal dilatation of retinal artery with hemorrhage can occur in all layers of retina and choroid with or without exudative changes.  

• Signs of Hypertensive choroidopathy which is presented as a Elsching spots or Siegrist streaks, which number of conditions have been reported to cause it, including hypertension, pre-eclampsia, eclampsia, renal failure, renal artery stenosis, and adrenal carcinoma.

• Optic disc examination should rule out papilledema, which presented in malignant hypertensive retinopathy.  

• Presence of Vitreous or pre-retinal hemorrhage or neovascularization documented as well.   

Diagnostic tests 

Fundus images 

Fundus image is a vital tool to document the severity and to follow up hypertensive retinopathy and macroaneurysm, as when there are sclerotic or vasoconstrictive changes, this means it is only mild hypertensive retinopathy. 

Exudative changes indicate moderate hypertensive retinopathy, and papilledema features malignant hypertensive retinopathy^[2]. 

Fundus images can document signs of choroidal retinopathy such as Elsching spots or Siegrist streaks; the same for macroaneurysm fundus image can document the hemorrhagic changes and bleeding level (retinal, subretinal, preretinal, etc…) and exudative changes and follow-up after treatment or observation. 

Optical Coherence Tomography (OCT)

OCT is useful to diagnose macular edema related exudative hypertensive retinopathy and macroaneurysm; OCT is helpful to determine treatment success in macular edema management follow-up. 

An increase in choroidal thickness and pigmentary epithelial detachments characterize hypertensive choroidopathy.

Fundus Fluorescein Angiography (FFA)

In malignant hypertensive retinopathy early phase, a capillary nonperfusion and microaneurysms formation and choroid filled in a dendritic fashion wherein late phase it shows leakage in a diffuse pattern.  

In hypertensive choroidopathy, the angiography shows patchy and delayed choroidal filling, as well as severe delays in retinal arterial filling with areas of retinal capillary nonperfusion.

FFA shows early hyperfluorescence from the macroaneurysm, which stains in late phases surrounded with hypofluorescence due to blood blockage.   

Note that the physician should obtain signed consent explaining the rare complications of FFA, including death 1/200000, and FFA facility should have an emergency plan in situ ^[3]. 

B-scan

B-scan echography is essential in cases of non-clear media due to vitreous hemorrhage or other media opacity to rule out retinal detachment. 

Systemic evaluation 

Although analysis not ordered routinely, ECG, Chest X-ray, fasting lipid profile, fasting glucose, and HbA1C along with serum creatinine and urinalysis to rule out any systemic risk factors, however referral to a primary care physician is a must to rule out risks of stroke or cardiovascular disease. 

Diagnosing patients with hypertensive retinopathy 

In patients with hypertensive retinopathy associated with increased risk of atherosclerotic diseases such as coronary artery calcification^[4] and left ventricular hypertrophy ^[5], hypertensive retinopathy accompanied with prognostic information about coronary heart disease mortality ^[6].    

In cases of moderate hypertensive retinopathy are at risk of developing clinical or lacunar stroke ^[7] where patients with retinal hemorrhage are at risk of developing hemorrhagic stroke^[8]. Patients with signs of hypertensive retinopathy are at risk of developing subclinical stroke and white matter atrophy more than patients without signs ^[9]. 

Mild to moderate hypertensive retinopathy may be associated with end-organ damage ^[10] such as microalbuminuria and renal impairment ^[11].  

Arteriovenous nicking and generalized vasospasm are signs of prolonged hypertension however retinal hemorrhages, microaneurysms, or focal arterial narrowing are signs of short-term hypertension ^[16] 

It is believed that generalized retinal arterial narrowing precedes hypertension, and normotensive people with this sign were more likely to develop hypertension and, among those with mild hypertension at baseline, were more likely to develop the severe stages.

Management patients with hypertensive retinopathy and macroaneurysm

Usually, hypertensive retinopathy warrants only systemic medical treatment of hypertension under the supervision of primary care physicians to lower blood pressure below 140/90 mmHg. However, a excluding other associated pathologies such as a diabetes or cardiovascular diseases is a must.

Systemic treatment may show improvement in vascular leak and vasospasm in acute hypertensive retinopathy but not for atherosclerotic changes in chronic hypertensive retinopathy ^[12].

In cases of malignant hypertensive retinopathy, urgent antihypertensive management indicated ^[17].

In cases of hypertensive retinopathy with proliferative changes, then panretinal laser photocoagulation indicated.

In cases complicated with macroaneurysm observation will lead to spontaneous resolution, laser treatment (applying three rows inducing moderate intensity burn with spot size 500μm adjacent to macroaneurysm) results are controversial ^[13] as it may reduce vision in cases of macular edema ^[14] along with the risk of occluding arteriole during treatment; however, studies showed that Anti-VEGF for monthly three consecutive injections might reduce macular edema, hard exudates, and improve retinal hemorrhage and macroaneurysm ^[15] .

In cases of persistent subretinal hemorrhage, it managed with a pneumatic displacement with tPA and in cases of non-resolving preretinal hemorrhage covering the center of the macula treated with YAG laser to induce hyaloidotomy so hemorrhage leak in the vitreous cavity for faster clearance. Pars plana vitrectomy indicated in cases of non-clearing vitreous hemorrhage and large macroaneurysm that cannot be treated with laser.

Prognosis and follow-up 

Coordination between an ophthalmologist and primary care physician to assess the degree of hypertensive retinopathy and compliance and resistance to systemic medications, as mentioned above, the sclerotic changes are not reversible, which may induce retinal vein or artery occlusion. 

Macular and optic disc edema induced by malignant hypertension may cause visual impairment. 

Hemorrhagic macroaneurysm holds a better prognosis than exudative macroaneurysm, especially in cases that have persistent submacular hemorrhage due to hemorrhagic necrosis or macular edema^[18], some cases of macroaneurysm may complicate into a macular hole which holds bad prognosis as well ^[19]. 

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These guidelines were reviewed and updated in December 2022