Hypertensive retinopathy: a review of existing classification systems and a suggestion for a simplified grading system

With the advent of sophisticated ophthalmological investigations and a better understanding of the pathophysiology and clinical or prognostic correlates of the fundal lesions in hypertension, the limitations of early classification schemes using simple ophthalmoscopic appearances are increasingly apparent. This review describes the existing classification systems for hypertensive retinopathy and their limitations, as well as the pathophysiological effects of hypertension on the retinal vasculature. A new and simpler grading system for hypertensive retinopathy is proposed, dividing the features according to prognosis into two categories of non-malignant vs malignant hypertension. Such a simpler, updated system for our medical practice has been long overdue.

Vasoproliferative tumors of the ocular fundus. Classification and clinical manifestations in 103 patients

OBJECTIVE

To describe the clinical features of vasoproliferative tumors of the ocular fundus and to propose a comprehensive classification of these tumors.

METHODS

A retrospective review of all cases that were diagnosed as acquired retinal hemangioma or vasoproliferative retinal tumor was conducted on the Ocular Oncology Service at Wills Eye Hospital, Philadelphia, Pa.

RESULTS

There were 129 vasoproliferative tumors in 113 eyes of 103 patients. The tumors were classified as idiopathic in 84 eyes (74%) and secondary to preexisting ocular disease in 29 (26%). Subclassification into solitary (88 eyes), multiple (17 eyes), and diffuse (eight eyes) involvement was made. Of the 84 eyes with idiopathic tumors, 73 (87%) had solitary tumors, five (6%) had multiple tumors, and six (7%) had diffuse tumors. The lesion was located in the inferior, inferotemporal, or temporal region of the fundus in 78% and developed within 6 mm of the ora serrata retinae in 88%. Associated vitreoretinal findings included intraretinal exudation (82%), secondary exudative retinal detachment (48%), vitreous cells (46%), vitreous hemorrhage (21%), preretinal macular fibrosis (31%), and macular edema (18%). Of the 29 eyes with secondary tumors, the tumor was solitary in 15 (52%), multiple in 12 (41%), and diffuse in two (7%). The most common preexisting ocular disease included intermediate uveitis (pars planitis) in eight eyes (28%), retinitis pigmentosa in six (21%), toxoplasmic retinitis in two (7%), toxocariasis in two (7%), retinochoroidal coloboma in two (7%), and traumatic chorioretinopathy in two (7%). Retinal pigment epithelial hyperplasia was a prominent feature that was adjacent to 58% of the secondary tumors. Overall, management of the 129 tumors consisted of observation in 63 (49%), cryotherapy in 54 (42%), laser photocoagulation in seven (5%), plaque radiotherapy in three (2%), and other modes of treatment in two (2%).

CONCLUSIONS

Vasoproliferative retinal tumors can be idiopathic, or they can develop secondary to congenital, inflammatory, vascular, traumatic, dystrophic, and degenerative ocular diseases. They can produce a variety of complications. Awareness and recognition of these tumors and differentiation from other retinal vascular tumors are important.

Idiopathic juxtafoveolar retinal telangiectasis. Update of classification and follow-up study

BACKGROUND

Idiopathic juxtafoveolar retinal telangiectasis may cause visual loss. The treatment of this disease is controversial.

METHODS

The authors reviewed the records of 140 patients with idiopathic juxtafoveolar telangiectasis. A classification scheme based on biomicroscopic and fluorescein angiographic findings is presented. In addition, the effect of photocoagulation on the natural history of the disorder is evaluated.

FINDINGS

Patients are categorized into three groups. Group 1 comprises 39 male patients with nonfamilial, easily visible telangiectasis and intraretinal exudation. The telangiectasis is unilateral in 94% of patients. The telangiectasia in this group is probably of developmental origin (Coats syndrome). Group 2 comprises 94 patients with occult juxtafoveolar telangiectasis, minimal exudation, superficial retinal crystalline deposits, and right-angle venules. Late in the course of the disease, foveolar atrophy, intraretinal pigment plaques, and subretinal neovascularization develop. The telangiectasis is acquired during middle age and is bilateral in 98% of patients. Group 3 comprises seven patients with bilateral easily visible telangiectasis, minimal exudation, and capillary occlusion. All of these patients had systemic disease, which was probably related to their eye disease.

CONCLUSION

Slow visual loss beginning in adulthood characterizes most of these patients. The telangiectasis appears to be caused primarily by retinal capillary leakage in group 1, capillary diffusion abnormalities in group 2, and capillary occlusion in group 3. Photocoagulation is probably beneficial for patients in group 1 and not for patients in group 2, at least before their development of subretinal neovascularization.

[The involutional vitreoretinal syndrome]

Ocular changes in elderly subjects are described, that may be regarded as manifestations of a disease, denoted by the author as the involution vitreoretinal syndrome. The subjective signs of the syndrome are floating 'moths', photopsias presenting as a 'lateral lightning', sudden appearance of a central macula (central positive scotoma). The objective signs are destruction and posterior detachment of the vitreous body, peripheral retinal dystrophy, stable light reflexes (coin-shaped, flap, etc.) on the fundus oculi, previously described by the author. The syndrome complications are fibroplasia of the fundus oculi central area, macular edema, perforation of the macula and characteristic lenticular changes. The author singled out the cases with combined changes of the vitreous body, fundus oculi and lens involvement as a lentivitreoretinal form of the involution vitreoretinal syndrome.

An updated classification of retinal detachment with proliferative vitreoretinopathy

The Retinal Society classification on proliferative vitreoretinopathy of 1983 has been updated to accommodate major progress in understanding of this disease. There are three grades describing increasing severity of the disease. Posterior and anterior location of the proliferations have been emphasized. A more detailed description of posterior and anterior contractions has been made possible by adding contraction types such as focal, diffuse, subretinal, circumferential contraction, and anterior displacement. The extent of the abnormality has been detailed by using clock hours instead of quadrants.

Causative factors of retinal detachment in macular holes

Two hundred nine macular holes of both pathologic myopia and idiopathic senile type were statistically analyzed to find out which factors cause retinal detachment in eyes with macular holes. The incidences of retinal detachment were as follows: 97.6% in myopia over -8.25 D, 67.7% in myopia between -8.0 and -3.25 D, and 1.1% in eyes under -3.0 D; 100% in widespread chorioretinal atrophy, 90.6% in spotty or lineal chorioretinal atrophy, 64.3% in myopic tigroid fundus, and 0% in eyes without myopic tigroid or atrophy; 96.0% in eyes with posterior staphyloma and 8.2% in eyes without it; 56.4% in posterior vitreous detachment [PVD] (+) eyes, 53.3% in PVD(+/-) eyes, and 51.9% in PVD(-) eyes. The statistically significant (P less than 0.05) factors that caused retinal detachment were refractive error, myopic chorioretinal change, and posterior staphyloma. There was no statistically significant difference regarding PVD.

[Individualization of X-flavimaculated macular dystrophy in hereditary macular dystrophies]

X-shaped macular dystrophy with flavimaculatus flecks is individualized of other heredo-macular dystrophies. This aspect was showed in two families with a retinal pigment epithelial dystrophy characterised by an X-shaped yellowish macular lesion and numerus flavimaculatus retinal flecks. Nine members were variously affected. The condition was bilateral, had a dominant inheritance, started in middle age with a slow-developing macular lesion. Visual functions were often minimally disturbed for two or three decades. Relations with others here-domacular dystrophy are discussed particularly with pattern dystrophy.

Evaluation of patients with obvious or suspected degenerative and dystrophic disorders of the retina, pigment epithelium and choroid. Experience from a Swedish referral center

Between August 1, 1982, and December 31, 1988, 487 patients with clinically established or suspected diagnosis of a hereditary degenerative or dystrophic disorder of the ocular fundus or of a disorder of the optic pathways were evaluated with an extensive set of clinical and electrophysiological tests, 67% of the patients were referred from other eye departments. In order of magnitude the most frequently encountered diagnoses were: 1) 'functional' disturbances (18%), 2) disorders of the optic nerve (9%), 3) retinitis pigmentosa (8%), 4), 5) and 6) progressive cone dystrophy, disorders of the central optic pathways, and fundus flavimaculatus/Stargardt's disease (5% each), and 7) choriocapillaris atrophy (4%). Choriocapillaris atrophy affected older patients than retinitis pigmentosa (P less than 0.001). A male preponderance was observed for juvenile retinoschisis (P less than 0.005) and congenital stationary night blindness (P less than 0.05), and a female dominance in the groups of patients with 'functional' symptoms (P less than 0.01). A specific diagnosis was established in 469 patients. After exclusion of 16 patients referred because of a known hereditary disposition, 196 (43%) of the remaining 453 patients were referred under the same diagnosis as our final diagnosis, 153 (34%) under a different diagnosis and 104 (23%) without any clear diagnosis. Obviously, there is a need for regional centers specialized in these disorders.

Retinal break type and proliferative vitreoretinopathy in nontraumatic retinal detachment

In a retrospective study of 1180 consecutive eyes operated for retinal detachment, vitreous traction on the rent was the determining factor for the development of proliferative vitreoretinopathy (PVR). Round, multiple, small holes in equatorial degeneration (retinogenic) and macular holes in which no vitreous traction on the rent was found did not complicate with PVR. Retinal detachment caused by horseshoe or crescent-shaped tears with evidence of vitreous traction (vitreogenic) developed PVR to a variable degree: in 171 (25.8%) senile myopic, 19 (44.2%) senile-myopic aphakic, 23 (20.2%) typical aphakic, and 32 (78.1%) patients with giant tears. We also found that retinogenic retinal detachments affected younger age groups more than did vitreogenic retinal detachments.

[Electroretinographic problems in the diagnosis of diseases of the cones and macula]

From series of clinical cases, the authors expose how ERG is an essential element for the diagnosis of cone dysfunction with or without macular involvement. They show that to obtain an accurate diagnosis, precise proceedings must be chosen, using stimulation technics correctly selected. They study the advantage of focal or wide stimulations, of the level of the intensity of the stimulation and of the different colored filters. They propose a proceeding for adults examination. For young children, they discuss the advantages and limits of a particular proceeding.

Classification of proliferative vitreoretinopathy used in the silicone study. The Silicone Study Group

The Silicone Study is a multicenter randomized clinical trial that compares a long-acting gas with silicone oil for the surgical treatment of proliferative vitreoretinopathy (PVR). As part of the study, a topographic classification of PVR has been developed that is based on the characteristic patterns of retinal distortion produced by the contraction of proliferative membranes on the retina or within the vitreous base. This classification is used to document the extent and anatomic distribution of PVR present preoperatively and to help standardize the surgical treatment. Experience has shown that this classification facilitates the identification of these membranes and their systematic dissection, and the authors therefore suggest that it be used to augment the Retina Society classification of PVR.

Prevalence and significance of acquired immunodeficiency syndrome-related retinal microvasculopathy

We performed ophthalmologic examinations on 127 subjects with or at risk for human immunodeficiency virus (HIV) infection over a one-year period to determine the prevalence and significance of retinal cotton-wool spots and hemorrhages (AIDS-related retinal microvasculopathy). Of 26 asymptomatic homosexual men, of whom 13 were HIV seronegative and 13 were HIV seropositive, none manifested this retinopathy. Three of 34 patients (9%) with AIDS-related complex and 29 of 67 patients (43%) with AIDS manifested retinopathy on the initial examination. This difference in the prevalence of retinopathy between groups was statistically significant (P less than .05). Patients with AIDS demonstrated 7.2 times greater odds of manifesting retinopathy than patients with AIDS-related complex (P less than .05). Within the group of patients with AIDS, the T helper (CD4) to suppressor (CD8) cell ratio was significantly associated with retinopathy at the initial ocular examination. The CD4:CD8 ratio of the total group of AIDS and AIDS-related complex patients with retinopathy was significantly lower than that of patients without retinopathy (P less than .05). There was no significant association between retinopathy and any specific past or concurrent opportunistic infection or neoplasm. The presence of retinopathy was not associated with symptoms in any patient. The lesions of AIDS-related retinal microvasculopathy may be an important finding in the evaluation of patients suspected to have HIV-related disease.

X-linked cone dystrophy. An overlooked diagnosis?

The cone dystrophies can be subdivided into 3 functional stages: central cone disease, peripheral cone disease and diffuse cone disease, respectively. In the patient material of our clinic the sex distribution of patients presenting with te diffuse cone disease stage was abnormal: 22 males and 3 females. The authors suggest that the diagnosis X-linked cone dystrophy often is overlooked.

Classification of the stages of proliferative vitreoretinopathy in a refined experimental model in the rabbit eye

Eighty-four rabbit eyes injected intravitreously with tissue-cultured fibroblasts following gas compression of the vitreous were examined clinically over a period of 1 month. Detailed clinical descriptions of the extent of retinal changes were recorded. Clinical landmarks were determined and arranged into a new classification of this model of proliferative vitreoretinopathy (PVR). The proposed classification will allow easier communication between research groups using this model to study the treatment and prevention of PVR.

Retrolental fibroplasia: a five-year experience in a tertiary perinatal center

During a five-year period, 565 premature infants in a tertiary perinatal center were evaluated by binocular indirect ophthalmoscopy. One-hundred-ten infants had retinopathy of prematurity. Ten of these infants developed grade 5 cicatricial retrolental fibroplasia, whereas two fellow eyes remained stable at grade 2 retrolental fibroplasia. Surgical lensectomy and vitrectomy failed to improve vision or reattach the retina in any of those with grade 5 retrolental fibroplasia. In three operated eyes and two unoperated eyes secondary glaucomas developed. Five vitrectomized eyes are now known to have phthisis. The factors that modulate the transition from the benign, acute retinopathy of prematurity lesions to cicatrizing (scarring) lesions characteristic of retrolental fibroplasia remain unclear. Birth weight (less than 1000 g), multiple apneic episodes with concomitant ventilatory assistance with 100% oxygen, and inadvertent hyperoxemia during general anesthesia may be significant cicatrization factors.

Systemic hypertension and age-related maculopathy in the Framingham Study

Analysis of data on 1,828 subjects from the Framingham Heart and Eye Studies shows a small and consistent significant association between age-related maculopathy and systemic hypertension. The association was found using blood pressure and medical history data collected both 25 years before the eye examination and concurrently with the eye examination. Prevalence of age-related maculopathy progressively increases with increasing duration of systemic hypertension. Previous epidemiologic studies of the association between systemic blood pressure and age-related maculopathy have produced conflicting results. The failure of some studies to detect an association may have resulted from inadequate sample sizes to detect the small relative risks and problems in determining the duration of the systemic hypertension.

Electrophysiological analysis of Stargardt's disease fundus flavimaculatus group

Stargardt's disease-fundus flavimaculatus has four general distribution patterns in fundus appearance: (1) macular degeneration without flecks; (2) macular degeneration with perifoveal flecks; (3) macular degeneration with diffuse flecks; and (4) diffuse flecks without macular degeneration (Noble and Carr, 1979). Four cases corresponding each to the four subgroups were studied electrophysiologically by our new tests for the cone receptor cell (rapid off-response in the ERG) and for the retinal pigment epithelium (the hyperosmolarity response and the Diamox response). The results of our electrophysiological tests appear consistent with the histological findings by Klien and Krill (1967) and by Eagle et al. (1980), showing that the primary defect of fundus flavimaculatus is in the retinal pigment epithelium. Electrophysiologically, the severity of the disease correlated well with each fundus pattern.

Outline for a comprehensive classification of retinal dystrophy and its consequences

Classification of all relevant factors is a prerequisite to the formulation of specific objectives to attain goals of prevention of retinal dystrophy (RD) and effective provision of services. National and international agreement on a classification is sought. This outline stresses the importance of a sound conceptual basis. The root meaning of dystrophy (difficult nourishment), and the concepts given in the World Organization's International Classification of Impairments, Disabilities and Handicaps are emphasized. The proposed classification is designed to be statistical as well as assisting diagnosis and case management. The scheme for RD entities takes into account special features, in contrast to most treatable eye diseases. Genetics is stressed because of the importance of genetic counseling and rapid research advances. Three appendices illustrate portions of a comprehensive classification already in operation at the Retinal Dystrophy Service of NSW.