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Key Features

  • The clinical manifestations vary according to

    • The degree and rapidity of rise in blood pressure

    • The underlying state of the ocular circulation

  • Chronic hypertension accelerates the development of atherosclerosis

Clinical Findings

  • Occurs in young patients with abrupt elevations of blood pressure, which may occur in

    • Pheochromocytoma

    • Hypertensive crisis with retinopathy (previously known as malignant hypertension)

    • Preeclampsia-eclampsia

  • Can be a surrogate marker for current and future nonocular end-organ damage

  • In chronic hypertension

    • Retinal arterioles become more tortuous and narrow and develop abnormal light reflexes ("silver-wiring" and "copper-wiring")

    • There is increased venous compression at the retinal arteriovenous crossings ("arteriovenous nicking"), an important factor predisposing to branch retinal vein occlusions

    • Flame-shaped hemorrhages occur in the nerve fiber layer of the retina

Diagnosis

  • Detected by non-mydriatic fundal photography

  • Acute elevations of blood pressure

    • Result in loss of autoregulation in the retinal circulation, leading to the breakdown of endothelial integrity and occlusion of precapillary arterioles and capillaries that manifest as cotton-wool spots, retinal hemorrhages, retinal edema, and retinal exudates, often in a stellate appearance at the macula

  • Vasoconstriction and ischemia in the choroid result in exudative retinal detachments and retinal pigment epithelial infarcts

    • These infarcts later develop into pigmented lesions that may be focal, linear, or wedge-shaped

    • The abnormalities in the choroidal circulation may also affect the optic nerve head, producing ischemic optic neuropathy with optic disk swelling

  • Fundal abnormalities

    • Are the hallmark of hypertensive crisis with retinopathy

    • Require emergency treatment

    • If marked, are likely to be associated with permanent retinal, choroidal, or optic nerve damage

Treatment

  • Control of blood pressure with antihypertensive medications (see Hypertension, Chronic) is key

  • However, precipitous reduction of blood pressure may exacerbate retinal, choroidal or optic nerve damage

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