Hypertensive retinopathy

Introduction to Hypertensive Retinopathy Hypertensional retinopathy (hypertensieretinopathy) refers to the continuous increase of systemic arterial blood pressure, causing blood-retinal barrier destruction, plasma leakage, formation of blood vessels in the blood vessels, retinal edema, hemorrhage, ischemia or exudation. In the case of severe disease, retinal detachment may occur. basic knowledge Proportion of disease: Chinese population incidence rate is 0.0088% Susceptible people: people with high blood pressure Mode of infection: non-infectious Complications: retinal artery occlusion retinal vein occlusion aneurysm edema ischemic necrosis

Causes of hypertensive retinopathy

Causes:

Increased arterial pressure is the main pathophysiological change and clinical manifestation of hypertension. Systemic small arterial stenosis is the basic factor for the increase of arterial pressure in hypertension. The central retinal artery is the only body that can be directly observed in living body. Small arteries, therefore, the fundus conditions in the course of hypertension often reflect the degree of damage of the body, kidney, brain and other organs, and have important significance for the diagnosis and prognosis of hypertension.

Pathogenesis:

When the hypertension rises sharply, the vascular tone of the retinal muscle arteries is stimulated by a myogenic-like self-regulation mechanism. For example, the blood pressure is continuously increased, the vascular tone is increased, and the lumen of the retinal blood vessels is reduced, and blood is generated. - Retinal barrier destruction, retinal oozing period, in the experimental hypertension with horseradish peroxidase tracer technology, can be found in the outer blood-retinal barrier of the retinal pigment epithelium and the inner retinal vessels located in the retinal vascular system Both have damage.

At the same time as the blood vessel wall is destroyed, the blood flow is reduced and ischemia. The appearance of cotton-like plaque is one of the signs of retinal ischemia. The cotton-floc-like plaque is the accumulation of axonal components in the nerve fiber layer, which is near the axon in the ischemic area. Mitochondria, lamellar dense bodies and axoplasmic matrix in the distal and distal ends.

When the blood pressure is slightly elevated, the middle layer of the retinal artery is moderately proliferated. If the hypertension persists for a period of time, the retinal vascular dysfunction is accompanied by the loss of the wall muscle cells, and these blood vessels will exhibit a self-regulating mechanism and the destruction of the blood vessel wall. The patient may develop thrombosis and promote the process of ischemia. During the chronic repair period, the blood vessels are re-recovered, the non-perfused arteries are re-channelized, the capillaries are reopened, and the smooth epithelium surrounds the capillaries when they form collaterals. But even with the recovery of these blood vessels, it is often impossible to restore the visual function of the original infarcted retina.

Hypertension retinopathy prevention

1, develop good habits, should avoid alcohol and tobacco, long-term smoking, which will lead to arteriosclerosis. A large amount of smoking in a short period of time will increase blood pressure. Therefore, excessive alcohol and tobacco are the causes of fundus vascular lesions.

2, prevention of high blood pressure is also very important. If the blood pressure is too high, you should seek medical advice promptly, and with the doctor to take the medicine on time, you must avoid large fluctuations in blood pressure.

3, if you have cough symptoms, you must be treated in time. Because the capillaries of the middle-aged and elderly people are very brittle, repeated coughing will cause blood vessel rupture. Also keep the stool smooth.

4, usually keep the mood and blood pressure stable. Because excited emotions can easily raise blood pressure, and sad emotions can cause paralysis of small blood vessels. These are the causes of fundus vascular lesions.

Hypertensive retinopathy complications Complications retinal artery occlusion retinal vein occlusion aneurysm edema ischemic necrosis

Complications of retinal arteriosclerosis include central or branch retinal artery occlusion, central or branch retinal vein occlusion, giant hemangioma and preretinal membrane or proliferative vitreoretinopathy. After vascular occlusion, especially blood pressure controlled, blood vessels can be changed. However, due to the occurrence of ischemic necrosis in the acute phase, visual function may not recover.

Visual function in patients with hypertensive retinopathy is often unaffected by large lesions, as most lesions are scattered in the posterior pole, but in concurrent branch arteries or veins, macular edema, macular hemorrhage or exudation, macular capillary loss or macular The occurrence of retinal anterior membrane with internal limiting membrane fold affects central vision. Most patients with hypertensive retinopathy may have obvious visual symptoms after complications of cirrhosis.

Hypertensive retinopathy symptoms Common symptoms Uveitis clinic hypertensive fundus changes

Vasoconstriction

During vasoconstriction, elevated blood pressure stimulates soft and unhardened retinal arterial blood vessels, self-regulating to increase tension, and the retina is younger and more elastic. The greater the response, the clinical examination reveals limited retinal artery stenosis. If the course of disease lasts, there is a general stenosis.

2. Hardening period

If the elevated blood pressure is rapidly controlled during vasoconstriction by drug or surgery, the retinal blood vessels can return to normal without permanent lesions. If the hypertension persists for a period of time, a hardening change occurs. Clinically, the hardened blood vessels have Features include:

1 The artery is generally narrow.

2 arteriovenous depression.

3 The hardening of the blood vessel wall causes a change in the light reflection of the blood vessel wall.

4 vascular tortuosity.

5 The angle of arteries and arterioles is increased. Although these retinal vascular changes can also be found in some "normal" people, they are definitely more common in patients with hypertension. These changes are related to old age in these two kinds of people. Clinical features such as "arterial straightening, arterial thinning, arteriovenous crossover and widening of light reflex" are not reliable indications for hypertensive vascular disease.

(1) arterial stenosis: small arteries are generally narrow, with or without localized contraction, is a useful indicator for identifying hypertension. Vascular stenosis is extremely difficult to quantify. Some authors compare arterial diameter with vein, but veins often expand, not suitable As a reference standard, early stenosis is most common in the smaller branches after retinal artery 2 or 3, and it must be noted that many eye diseases such as high myopia, uveitis and retinal dystrophy can lead to retinal vascular stenosis, and the examiner is estimating arterial stenosis. It must be judged clinically.

(2) The change of the arteriovenous intersection can be objectively determined compared with the arterial stenosis. The arterial vein is in front of the vein, and the arteriovenous depression sign is visible. Otherwise, it is not. This feature can be divided into 3 levels:

1 mild arteriovenous depression.

2 moderate arteriovenous depression.

3 branch vein occlusion, mild indentation, varicose veins under the arteries, and early concealment, moderate depression, venous stenosis and narrowing and deviation (Gunn sign), veins outside the cross A little further away, there is a slight swelling called a venous "slope", and a level 3 lesion is seen at the distal end of the arteriovenous intersection with bleeding and exudation of the venous obstruction.

(3) Arterial wall sclerosis is often estimated by light reflection from the vessel wall. Although this change can be seen in older patients, it still provides a useful parameter for estimating the effect of chronic hypertension on the vessel wall. Level 3:

1 Mild light reflection increases.

2 "copper wire".

3 "silver-like", the early arterial wall light reflection of the hardening process is widened, and then gradually increases, and finally covers the entire front of the arteriovenous, the appearance of the polished copper wire, the extreme manifestation of arteriosclerosis, the thickening of the blood vessel wall and It changes like a white silver filiform, but even then, there may still be blood flow.

(4) Arterial tortuosity seen in chronic hypertension: the intraluminal pressure is increased, the muscle fibers are gradually transparent and fibrotic, so that the length of the artery increases, and the retinal artery is in a curved stroke in the retina, but it should be associated with a common benign Distal retinal artery tortuosity identification.

(5) Another useful sign of hypertensive vascular disease is the angle of the large branch of the artery, especially the second or third branch. The higher the blood pressure, the larger the angle of the branch, and the angle of the branch artery of the milder is 45. ° ~ 60 °, moderate branch angle is 60 ° ~ 90 °, heavy branch angle is greater than 90 °.

In the period of hypertensive retinopathy, there may be no active rupture of the blood-retinal barrier by fluorescein angiography and vitreous fluorometry. However, if the pressure is suddenly or progressively elevated, the patient may enter the hypertensive retinopathy. period.

3. Exudation period

The exudation period of hypertensive retinopathy may be accompanied by or subsequent to the vasoconstriction or sclerosing phase of hypertensive choroidal lesions or hypertensive retinopathy. The appearance of this phase indicates that the perfusion pressure of the retina has exceeded its physiological self-regulation mechanism, resulting in The blood-retinal barrier is destroyed, liquid and blood cells are leaked from the circulatory system, blood vessel walls are broken and blood flow is abnormal, and ischemia often occurs.

One of the early signs of exudative retinopathy is small linear or flame-like hemorrhage, mostly in the nerve fiber layer around the optic disc. The linear form of hemorrhage is due to:

1 occurs in the retinal nerve fiber layer.

2 The blood leaking from the blood vessels extends along the axons of the ganglion cells, and the bleeding may also be spotted or spotted; if the hemorrhage occurs in the deep layer of the retina, it has an oval contour, which is limited by the Müller cell protrusion due to the diffusion of the leaked blood, and may occasionally occur. The blood penetrates the inner limiting membrane and is located under the vitreous. In the posterior pole, there is a boat-like hemorrhage. The hard waxy exudation indicates that the blood vessels leak out plasma lipoprotein, phospholipids, cholesterol and triacylglycerol. This exudation is shiny yellow, most Often distributed in the posterior pole, can be star-shaped in the central part of the macula, radiating from the macular area along the Henle fiber layer, some patients with hard exudation can form a halo around a giant hemangiomas or clusters of leaking microvessels Tumors, known as annular retinopathy due to this rigid appearance of a ring-like appearance.

Cotton-like spots are gray or yellow spots, hairy at the edges, mostly in the retinal nerve fiber layer, mostly in the posterior pole, especially around the optic disc. The long axis of the cotton wool plaque is often at right angles to the direction of the nerve fiber layer, most often in the retinal blood vessels. On the shallow side, after a period of time, the cotton-like spots may have a granular appearance and eventually disappear. At this time, the appearance of the retina becomes thin, and the inner limiting film has an irregular appearance of reflection. These parts are called "plaque depressions", indicating that there is an infarction. The loss of localized inner retinal structure, fluorescein angiography often shows some non-perfused areas around the cotton-like plaque, as well as capillary dilatation and microangioma, collateral vessels with bead-like vascular changes, and retina Tissue fluorescein staining.

Examination of hypertensive retinopathy

1. No special laboratory inspections.

2. Ophthalmoscopy: It has important application value in the progression of hypertensive fundus changes. Fundus fluorescein angiography has different clinical manifestations in different stages of the lesion.

Diagnosis and diagnosis of hypertensive retinopathy

diagnosis

The diagnosis is based on the history and control of hypertension combined with fundus changes.

Differential diagnosis

Lesions at the intersection of retinal dynamics and statics, such as retinal arteriosclerosis caused by other causes, such as inflammation, can be identified from the patient's general condition and local characteristics of the eye.

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