Evolution of hypertensive retinal vascular disease: correlation between clinical and postmortem observations

Multimodal Imaging of Elschnig Spots: A Case of Simultaneous Hypertensive Retinopathy, Choroidopathy, and Neuropathy

A 65-year-old woman with chronic hypertension, chronic renal insufficiency, and schizophrenia self-discontinued her medications and presented complaining of decreased vision; she was found to have a blood pressure of 256/156 and visual acuity 20/70 OD. In the emergency department, her blood pressure was rapidly lowered to a nadir of 134/104. During the course of her hospitalization, her visual acuity declined from 20/70 to 20/200 OD in parallel with a decline in her renal function. Multi-modal imaging revealed simultaneous hypertensive retinopathy, choroidopathy, and optic neuropathy. Autofluorescence can play an important role in the diagnosis of hypertensive choroidopathy.

Microvascular dilatation after haemodialysis is determined by the volume of fluid removed and fall in mean arterial pressure

BACKGROUND/AIMS

The effects of haemodialysis on the microcirculation are poorly understood. This study examined the changes in small vessel calibre.

METHODS

24 patients (including 12 males, median age 62.5 years, range 30-87) underwent digital retinal photography immediately before and after routine haemodialysis. Arteriolar and venular calibres were measured from the images by a trained grader using a highly reproducible, computer-assisted method.

RESULTS

Patients had an average 2.0 ± 0.3 litres of fluid removed with dialysis, and their mean arterial blood pressure fell by 6.8 mm Hg (CI 13.8-0.2, p = 0.06). Retinal arteriole calibre did not change (mean difference 2.3 µm, CI -1.1 to 5.7, p = 0.17) but the venules dilated (mean difference 12.7 µm, CI 7.3-18.3, p < 0.001). Calibre returned to baseline by 2 h. Venules dilated less in diabetics than non-diabetics (mean difference -6.2 µm, CI -9.6 to -2.9, p < 0.01). Retinal venular dilatation correlated positively with the volume of fluid removed per kilogramme body weight (5.9, CI 0.2-11.5, p = 0.04), and negatively with the fall in mean arterial pressure (-0.36, CI -0.72 to -0.01, p < 0.05) after adjusting for age, gender, diabetes and dyslipidaemia.

CONCLUSION

Haemodialysis is associated with systemic venular dilatation.

The microvasculature in chronic kidney disease

BACKGROUND AND OBJECTIVES

Individuals with chronic kidney disease (CKD) stages 3 to 5 have an increased risk of cardiac and other vascular disease. Here we examined the association of CKD 3 to 5 with small vessel caliber.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This was a cross-sectional observational study of 126 patients with CKD stages 3 to 5 (estimated GFR [eGFR] <60 ml/min per 1.73 m(2)) and 126 age- and gender-matched hospital patients with CKD 1 or 2. Retinal vessel diameters were measured from digital fundus images by a trained grader using a computer-assisted method and summarized as the central retinal artery equivalent (CRAE) and central retinal vein equivalent (CRVE).

RESULTS

Patients with CKD 3 to 5 had a smaller mean CRAE and CRVE than hospital controls (139.4 ± 17.8 μm versus 148.5 ± 16.0 μm, P < 0.001; and 205.0 ± 30.7 μm versus 217.4 ± 25.8 μm, respectively; P = 0.001). CRAE and CRVE decreased progressively with each stage of renal failure CKD1-2 to 5 (P for trend = 0.08 and 0.04, respectively). CKD and hypertension were independent determinants of arteriolar narrowing after adjusting for age, gender, diabetes, dyslipidemia, and smoking history. Patients with CKD 5 and diabetes had a larger mean CRAE and CRVE than nondiabetics (141.4 ± 14.9 μm versus 132.9 ± 14.2 μm; 211.1 ± 34.4 μm versus 194.8 ± 23.8 μm).

CONCLUSIONS

The microvasculature is narrowed in patients with reduced eGFR.

Quantification of topological changes in retinal vascular architecture in essential and malignant hypertension

OBJECTIVE

Grading of hypertension severity by fundoscopic appearance is difficult and inaccurate. We investigated whether essential hypertension (EHT) and malignant phase hypertension (MHT) were associated with quantifiable abnormalities of the topology and architecture of the retinal circulation.

METHODS

The topology and architecture of the retinal microvasculature were compared in images from 20 normotensive subjects, 20 patients with EHT and 20 patients with MHT. Digitized retinal photographs were analysed by a novel multiscale image analysis method using a semi-automated program to quantify geometrical and topological properties of arteriolar and venular trees.

RESULTS

EHT was associated with an increase in the arteriolar length-to-diameter ratio (P < 0.01). There were also alterations in arteriolar topology indicative of rarefaction, including a marked reduction in the number of terminal branches in EHT (P < 0.01). These changes in the arteriolar network were exaggerated in MHT and there was also increased venular tortuosity and venular rarefaction in MHT compared with normotensive subjects.

CONCLUSIONS

Hypertension is associated with marked topological alterations in the retinal vasculature, and quantification of these changes may be a useful novel approach to the assessment of target organ damage in hypertension.

Impact of current and past blood pressure on retinal arteriolar diameter in an older population

OBJECTIVE

To examine the effects of current and past blood pressure on retinal arteriolar diameter in a general older population.

DESIGN

Cross-sectional and longitudinal studies.

SETTING

Population-based cohort study of older residents from an area west of Sydney, Australia.

PARTICIPANTS

Two thousand three hundred and thirty-five individuals (n = 2335) (aged > or = 54 years) who attended the 5-year follow-up Blue Mountains Eye Study during 1997-99.

MAIN OUTCOME MEASURES

A computer-assisted method measured vessel diameters from digitized right eye retinal photographs. The narrowest quintile of central retinal arteriolar equivalent or arteriole-to-venule ratio (AVR) defined generalized arteriolar narrowing. Blood pressure was measured using a mercury sphygmomanometer.

RESULTS

After simultaneous adjustment for age, sex, body mass index, smoking and current or past blood pressure, elevated levels of both current and past blood pressure were associated with narrower retinal arterioles [Ptrend = 0.009 and 0.007 for current and past systolic blood pressure (SBP), respectively] and lower AVR [Ptrend = 0.001 and 0.0009 for current and past diastolic blood pressure (DBP), respectively]. Generalized arteriolar narrowing was associated with both current blood pressure [adjusted odds ratio (OR) 2.4, 95% confidence interval (CI) 1.5-3.8 for the highest versus lowest quintile of current DBP] and past blood pressure (adjusted OR 1.7, 95% CI 1.1-2.6, for the highest versus lowest quintile of past DBP). Hypertension duration or control status at baseline had no additional effect on arteriolar diameter after adjusting for current blood pressure.

CONCLUSIONS

Our data document the independent effects of both current and past blood pressure on small vessel calibre in the retina, suggesting that retinal arteriolar narrowing may result from the cumulative effects of long-standing hypertension.

The light reflex in retinal vessels and its relation to age and systemic blood pressure

The light streak characteristics on retinal vessels were studied by microdensitometry on fundus photographs. We compared the width and the intensity of the reflex in a young group (mean: 19.7-year-old; n = 40) and in an older group (mean: 45.3-years-old; n = 22) of normal subjects. By subgrouping according to age and blood pressure levels, we studied possible effects of these parameters on the light streak. We found higher intensity of reflection from both arteries and veins in the older group (P less than 0.01). This effect seemed mostly related to the age of the subjects. We also registered a relation between systolic blood pressure and intensity of reflection from veins in the young group (P less than 0.03). Optical changes in the vessel walls in the ageing process and intravascular pressure effects on the indices of refraction in the erythrocytes/plasma may account for these findings. The width of the reflex was not found to be related to either the age or the blood pressure level of the subjects.

Ischemic optic neuropathy as a possible early complication of vascular hypertension

Eighteen patients with idiopathic optic neuropathy lacked symptoms and signs of cardiovascular and cerebrovascular disease, especially when compared to three groups of patients with sudden visual loss caused by retinal infarction, transient ischemia, and cerebral infarction. Many patients in the latter groups had hypertension, carotid bruits, heart disease, transient ischemic attack, and stroke. But among the patients with ischemic optic neuropathy, hypertension was the only evidence of cardiovascular disease, affecting 44% of the patients. We argue that, in many cases, ischemic optic neuropathy represents a direct and early complication of hypertension arterial disease affecting small arterioles supplying the anterior part of the optic nerve. The pathologic process may thus be similar or identical to lacunar infarction of the brain.

Correlation between retinal and pelvic vascular status: a determinant factor in patients undergoing pelvic irradiation for gynecologic malignancy

The degree of arteriolar sclerosis in pelvic vessels has previously been shown to be related to the incidence of radiation-related enteric and genitourinary injury. Retinal vessel changes were compared to pelvic vascular changes in 48 patients, half of whom were either diabetic or hypertensive. There was an absolute correlation between retinal vessel changes and bowel or cervicovaginal vessel changes in 74% of the cases, and only one patient had a marked (more than one grade) discrepancy between retinal and pelvic vascular status. The findings of this investigation suggest that funduscopic examination of the retina can provide useful information concerning the extent of vascular disease in structures normally present in the field of pelvic irradiation.

Cardiovascular disease in patients with retinal arterial occlusion

103 patients with retinal-artery occlusion causing permanent visual-field defect were examined clinically and angiographically to assess the extent of cardiovascular disease. The 68 patients with branch-artery occlusion had a higher prevalence of previous transient episodes, ischaemic and valvular heart-disease, and more often had an operable lesion in the carotid artery than had the 35 patients with central-artery occlusion who were more often hypertensive, had fewer warning attacks, a greater prevalence of complete carotid occlusion, and fewer operable carotid lesions. The two types of retinal vascular occlusion show aetiological differences; branch occlusion is more often embolic and should be fully investigated for carotid and cardiac disease. These measures are less often of practical importance in patients with central-artery occlusion.

Macular and perimacular vascular remodelling sickling haemoglobinopathies

The posterior pole vasculature of 100 patients with different sickling haemoglobinopathies was studied prospectively over a period of three years. Various abnormalities of the posterior pole vasculature were seen in 29 per cent of the patients. Continuous remodelling of the macular and perimacular vasculature occurred. Visual acuity was variably affected and sometimes remained intact.

Ischaemic papillopathy. Clinical and fluorescein aniographic review of forty cases

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