From the Guidelines
Hypertension has a significant impact on the peripheral vascular retina in hypertensive retinopathy, leading to retinal vein occlusions, macular edema, and vision loss, emphasizing the need for aggressive blood pressure control to prevent these complications. The effects of hypertension on the peripheral vascular retina are multifaceted, involving retinal vascular leakage, intraretinal hemorrhages, and increased intravenous pressure 1. The major risk factors for retinal vein occlusions, a common manifestation of hypertensive retinopathy, include systemic arterial hypertension, arteriosclerosis, and diabetes 1.
Key Considerations
- Hypertensive retinopathy occurs when chronically elevated blood pressure damages retinal blood vessels, leading to arteriolar narrowing, hemorrhages, exudates, and in severe cases, optic disc edema.
- Controlling blood pressure is crucial as it can halt progression and sometimes reverse early retinopathic changes, preventing vision loss and indicating improved control of systemic hypertension.
- Lifestyle modifications including sodium restriction (<2.3g daily), regular exercise (30 minutes most days), weight management, and smoking cessation are essential adjunctive measures.
Management
- The primary treatment involves aggressive management of hypertension using antihypertensive medications such as ACE inhibitors (like lisinopril 10-40 mg daily), calcium channel blockers (amlodipine 5-10 mg daily), or angiotensin receptor blockers (losartan 50-100 mg daily) 1.
- These medications should be titrated to achieve a target blood pressure below 130/80 mmHg, as recommended for patients with diabetes and hypertension 1.
- Regular monitoring of blood pressure at home twice daily is recommended, along with comprehensive eye examinations every 6-12 months to monitor progression.
- For severe cases with macular edema or neovascularization, referral to an ophthalmologist for possible laser photocoagulation or anti-VEGF injections may be necessary.
From the Research
Effects of Hypertension on the Peripheral Vascular Retina
- Hypertension can cause damage to the retinal microcirculation and the retinal nerve fiber layer (RNFL), leading to progressive and painless vision deterioration in some patients 2.
- The harmful effect of increased blood pressure on the eye is not only limited to hypertensive retinopathy but can also lead to an exacerbation of diabetic retinopathy (DR) and an increase in intraocular pressure (IOP) 2, 3.
- Hypertensive retinopathy can be an indicator of other hypertensive complications such as neurologic and cardiac complications 4.
- Microvascular changes in the retina are reversible in well-controlled hypertension 4.
- Proper treatment of hypertension can reduce the development and progression of diabetic retinopathy and, thus, visual loss due to severe retinal diseases such as retinal vascular occlusion (artery and vein), retinal arteriolar emboli, macroaneurysm, ischemic optic neuropathy, and age-related macular degeneration 4, 3.
Retinal Changes in Hypertensive Retinopathy
- Hypertensive retinopathy is characterized by retinal microvascular signs that develop in response to raised blood pressure, including exudative changes such as macular edema, hemorrhages, and serous macular detachment 5.
- These changes can lead to visual decline and can be reversed with treatment, such as intravitreal bevacizumab 5.
- The severity of hypertensive retinopathy can be graded, with grade III or IV indicating more severe disease 6.
- Patients with grade III or IV hypertensive retinopathy may be at higher risk for adverse outcomes, including increased healthcare utilization and mortality 6.