Hypertensive

• Can lead to retinal vascular occlusion
• Malignant HTN:

  • acute rise in blood pressure
  • >180 systolic and >120 diastolic
  • Causing acute end organ damage
  • Manifests as swelling of the optic disc and a form of retinopathy
• Further investigations for hypertension may include:

  • Tests to confirm evidence of end-organ damage (e.g. urinalysis, ECG and U&Es)
  • Tests to confirm the cause of hypertension (e.g. secondary causes)
• Symptoms with malignant HTN:

  • Intermittent blurring of vision
  • Visual field defects
  • Headache
  • Flushed and red appearance of the face
  • Nausea and vomiting
  • Sudden painless loss of vision due to vessel occlusion
  • Signs of end-organ damage e.g. HF, AKI and chest pain
• Characteristics on fundoscopy:

  • Grade 1 - subtle, generalised arteriolar narrowing
  • Grade 2 - focal narrowing, compression of venules at sites of arteriovenous crossing (AV nipping)
  • Grade 3 - features similar to diabetic retinopathy - retinal haemorrhages, hard exudates and cotton wool spots
  • Grade 4 (typically malignant HTN)- all features of grade 3 plus optic disc swelling
• In a patient suspected of malignant or accelerated hypertension, NICE recommends referral for same-day specialist assessment if there are:

  • Signs of retinal haemorrhage and/or papilloedema on fundoscopy
  • Life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure or signs of acute kidney injury
• Intravenous anti-hypertensives such as nitroprusside, labetalol and nicardipine may be used to further control blood pressure.
• Complications:

  • Other retinal vascular disease - vessel occlusion, ischaemia, neovascularistion, vitreous haemorrhage and tractional retina detachment
  • Progression of pre-existing diabetic retinopathy