Signs Of Hypertensive Retinopathy Research Articles

Optical coherence tomography angiography value for detection of early retinal microvascular changes in systemic hypertension

Purpose The aim of this study was to assess the macula and optic disc vessel density (VD) and perfusion and the anatomical alterations at the fovea and optic nerve in chronic treated hypertension (HTN) patients who exhibited no signs of hypertensive retinopathy using optical coherence tomography angiography (OCTA). Patients and methods This is a prospective case–control study that included 37 participants. They were subdivided into two groups: the hypertensive group that included 22 patients (mean age=51.9±5.9 years), with no clinically evident signs of hypertensive retinopathy, and the control group that included 15 individuals (mean age=48.8±3.7 years) with no known history of HTN or other chronic systemic diseases. OCTA scans covering a 6.0×6.0 mm area for the macula and a 4.5×4.5 mm region for the optic nerve head were performed to evaluate the VD, the foveal avascular zone area, macular thickness, and retinal nerve fiber layer (RNFL) thickness. The correlation of the VD measurements with the RNFL thickness was evaluated. Results The hypertensive patients exhibited a significantly lower overall mean macular VD (45.8±6.0) compared to the control group (48.5±2.9, P=0.017). In addition, they exhibited a significantly lower superficial VD in the superior hemifield (46.4±5.3 and 48.6±2.9, respectively, P=0.030). On the other hand, the deep vascular density in the superior hemifield showed no significant difference between the two groups. In addition, the hypertensive patients were found to have a significantly lower average RNFL thickness (103.2±17.8 μm) compared to the control group (117.1±14.1 μm, P=0.001), with specific statistically significant reductions in the superior (P=0.002) and inferior (P=0.004) sectors. Although the central ganglion cell-inner plexiform layer thickness did not reach statistically significant difference between the two groups (HTN: 50.7±12.0 μm vs. control: 55.7±8.8 μm, P=0.055), the hypertensive group exhibited statistically significant reductions in the ganglion cell-inner plexiform layer thickness in the superior (P<0.001), inferior (P=0.002), nasal (P=0.003), and temporal (P=0.001) sectors compared to the controls. There was no statistically significant difference in the size of the foveal avascular zone between the two groups. Conclusion OCTA revealed subclinical alterations in the retinal microvasculature parameters among the hypertensive patients without clinical signs of hypertensive retinopathy, in comparison to normotensive individuals.

Optical coherence tomography angiography assessment of retinochoroidal microcirculation differences in preeclampsia

BackgroundTo investigate microvascular changes in pregnant women with preeclampsia using optical coherence tomography angiography (OCTA) and compare the results with healthy pregnant and non-pregnant subjects. MethodsSuperficial capillary plexus (SCP), deep capillary plexus (DCP) choriocapillaris (CC) vessel density (VD) and foveal avascular zone area (FAZ), retina, retinal nerve fiber layer (RNFL), the ganglion cell layer (GCL) and the choroidal thickness were examined and compared in preeclamptic pregnant (group 1), healthy pregnant women (group 2) and non-pregnant, age-matched female controls (group 3). The correlations of the parameters with each other and with blood pressure were evaluated. ResultsNo significant difference was found between the groups when retinal, RNFL and GCL thickness values (p> 0.05). The choroidal thickness values were significantly lower in group 1 than in group 2 (p = 0.029). The central foveal VD of the SCP and DCP was significantly lower in group 1 compared to groups 2 and 3 (p = 0.03, p< 0.01 respectively). The mean VD of the SCP was significantly higher in groups 1 and 2 than in group 3 (p = 0.01). The FAZ area was statistically significantly lower in group 3 than in group 2 (p = 0.032). The CC VD was lower in group 3 compared to the other groups in all measurements (p < 0.01).The FAZ area was positively correlated with systolic blood pressure in group 1. ConclusionThe use of OCTA, a non-invasive imaging technique, to assess the retinal microcirculation appears to have the potential to in the early diagnosis or follow up in preeclampsia before signs of hypertensive retinopathy.

STUDY OF OCULAR MANIFESTATIONS IN PATIENT WITH CHRONIC KIDNEY DISEASE IN TERTIARY CARE RURAL HOSPITAL

Purpose: To study the occurrence of various ocular manifestations exhibited by patients with Chronic Kidney Disease(CKD) and to analyse the findings. Materials and Methods: An observational, cross sectional, descriptive study was conducted at a tertiary care hospital after the approval of ethical committee for duration of 1year (July 2022- July 2023). A total of 50 patients of all age group, either sex, diagnosed with CKD irrespective of the haemodialysis statuswere evaluated. Detailed history and examination including visual acuity, anterior segment andfundus examination with direct and indirect ophthalmoscope was conducted. Result:Majority of CKD cases were noted in the age group of more than 60 years (40%) with male predominance of 66%.Out of 50 cases, 13(26%) were hypertensives, 8(16%) were diabetics and 3 patients had both.Out of 50 patients,6(12%) and 13(26%) showed signs of hypertensive and diabetic retinopathy respectively. Retinal detachment was noted in 2 patients, one had signs of pathological myopia and vitreous hemorrhage was noted in 1 patient. Conclusion:Most patients of CKD are detected in advanced stages. Hence it becomes imperative to detect CKD at an early stageand retard the progress of renal disease. Eye can be used as a window to kidney status so that necessary treatment can be given before irreversible changes occur. Thus, early ocular screening is of utmost importance in such patients.

A literature review of hypertensive retinopathy: systemic correlations and new technologies.

Hypertensive retinopathy (HR) is the most common ocular manifestation of systemic arterial hypertension. This paper aims to summarize the current knowledge of HR, reviewing its classical features, such as epidemiology, pathophysiology, clinical manifestations, classifications, management and the most significant systemic correlations. We also provide an update on the latest advances in new technologies focusing on novel instrumental classifications. A literature search was performed to identify articles regarding HR listed in Embase, PubMed, Medline (Ovid) and Scopus database up to 1 December 2021. The reference lists of the analyzed articles were also considered a source of literature information. The following keywords were used in various combinations: hypertensive retinopathy, hypertension and eye, hypertensive retinopathy and systemic correlations, optical coherence tomography (OCT) and hypertensive retinopathy, optical coherence tomography angiography (OCTA) and hypertensive retinopathy, adaptive optics (AO) and hypertensive retinopathy. The authors analyzed all English articles found using the aforementioned keywords. All the publications were thoroughly reviewed to create a detailed overview of this issue. HR signs have a significative association with cardiovascular, cerebrovascular and other systemic diseases. Patients with arteriosclerotic changes and, at the same time, severe HR, are at increased risk for coronary disease, peripheral vascular disease, stroke and dementia. HR is even now diagnosed and classified by its clinical appearance on a fundoscopic exam that is limited by interobserver variability. New technologies, like OCT, OCTA, AO and artificial intelligence may be used to develop a new instrumental classification that could become an objective and quantitative method for the evaluation of this disease. They could be useful to evaluate the subclinical retinal microvascular changes due to hypertension that may reflect the involvement of other vital organs. The eye is the only organ in the human body where changes in the blood vessels due to systemic hypertension can be studied in vivo. All doctors should be familiar with this disease because it has been largely demonstrated that signs of HR are correlated to patient's health and mortality. Researchers should develop a new common, standardized, and objective method to assess hypertensive retinal changes; new technologies may have a significant role in this field. This review takes most of the literature published so far, including the OCTA studies in order to stimulate new points of reference to standardize parameters and new diagnostic markers of this disease.

Hypertensive eye disease

Hypertensive eye disease includes a spectrum of pathological changes, the most well known being hypertensive retinopathy. Other commonly involved parts of the eye in hypertension include the choroid and optic nerve, sometimes referred to as hypertensive choroidopathy and hypertensive optic neuropathy. Together, hypertensive eye disease develops in response to acute and/or chronic elevation of blood pressure. Major advances in research over the past three decades have greatly enhanced our understanding of the epidemiology, systemic associations and clinical implications of hypertensive eye disease, particularly hypertensive retinopathy. Traditionally diagnosed via a clinical funduscopic examination, but increasingly documented on digital retinal fundus photographs, hypertensive retinopathy has long been considered a marker of systemic target organ damage (for example, kidney disease) elsewhere in the body. Epidemiological studies indicate that hypertensive retinopathy signs are commonly seen in the general adult population, are associated with subclinical measures of vascular disease and predict risk of incident clinical cardiovascular events. New technologies, including development of non-invasive optical coherence tomography angiography, artificial intelligence and mobile ocular imaging instruments, have allowed further assessment and understanding of the ocular manifestations of hypertension and increase the potential that ocular imaging could be used for hypertension management and cardiovascular risk stratification.

The New Era of Retinal Imaging in Hypertensive Patients.

Structural and functional alterations in the microcirculation by systemic hypertension can cause significant organ damage at the eye, heart, brain, and kidneys. As the retina is the only tissue in the body that allows direct imaging of small vessels, the relationship of hypertensive retinopathy signs with development of disease states in other organs have been extensively studied; large-scale epidemiological studies using fundus photography and advanced semi-automated analysis software have reported the association of retinopathy signs with hypertensive end-organ damage includes the following: stroke, dementia, and coronary heart disease. Although yielding much useful information, the vessels assessed from fundus photographs remain limited to the larger retinal arterioles and venules, and abnormalities observed may not be that of the earliest changes. Newer imaging modalities such as optical coherence tomography angiography and adaptive optics technology, which allow a greater precision in the structural quantification of retinal vessels, including capillaries, may facilitate the assessment and management of these patients. The advent of deep learning technology has also augmented the utility of fundus photographs to help create diagnostic and risk stratification systems. Particularly, deep learning systems have been shown in several large studies to be able to predict multiple cardiovascular risk factors, major adverse cardiovascular events within 5 years, and presence of coronary artery calcium, from fundus photographs alone. In the future, combining deep learning systems with the imaging precision offered by optical coherence tomography angiography and adaptive optics could pave way for systems that are able to predict adverse clinical outcomes even more accurately.

Associations of cardiovascular diseases and type 2 diabetes with ophthalmic diseases in a population sample over 55 years old

Aim. To study associations of cardiovascular diseases and type 2 diabetes (T2D) with ophthalmic diseases in a population sample of men and women from middle to old age (Novosibirsk).Material and methods. The population cohort was initially studied in 2003-2005 (n=9360, 45-69 years old, Novosibirsk, the Health, Alcohol and Psychosocial factors in Eastern Europe (HAPIEE) project). At the second survey (2015-2017) in a random subsample (n=1011), the following ophthalmic diseases were identified: hypertensive retinopathy (HR), diabetic retinopathy (DR), cataract, glaucoma, age-related macular degeneration (AMD), optic disc abnormalities, etc.Results. The prevalence of HR signs in persons with and without hypertension (HTN) was 81 and 46%, respectively (p&lt;0,001). This association persisted regardless of other factors (odds ratio, 2,27 (95% confidence interval: 1,78-4,17). The prevalence of AMD, cataract and DR increased in HTN, but associations were largely explained by metabolic factors in multivariate models. People with T2D more often than without T2D had signs of DR (9,3 vs 0,4%, p&lt;0,001), AMD (22 vs 17%, p=0,042) and glaucoma (14 vs 7%, p=0,001). Associations of T2D with DR and glaucoma persisted regardless of other factors. Individuals with carotid atherosclerosis (CA) were 1,6 times more likely to have HR than those without CA when adjusted for sex, age, and smoking (p=0,013).Conclusion. In the surveyed population sample of mainly elderly people, a number of associations between cardiometabolic and common ophthalmic diseases were revealed. The identified comorbidities may have important therapeutic and prophylactic applications in an aging population.

Role of pattern electroretinogram in assessment of retinal dysfunction in hypertensive patients

Background Hypertension is a major health problem in both developing and developed countries. Hypertension causes retinal structural and functional impairment within the ganglion cell layer. Pattern electroretinogram (PERG) offers an objective simple tool for assessment of retinal ganglion cell function. Aim of the work: To assess retinal dysfunction in hypertensive patients with or without signs of retinopathy using PERG. Materials and methods This is a case control study, including ninety-eight eyes. Twenty-eight eyes of healthy subjects served as a control group (group I) and seventy eyes of patients with systemic hypertension, who were further subdivided into group II including 39 eyes of hypertensive patients with normal fundus and group III including 31 eyes of patients with signs of hypertensive retinopathy. All subjects were subjected to ophthalmological examination and electrophysiological assessment using PERG. Results PERG implicit times were significantly prolonged and amplitudes were significantly reduced in patients with established hypertensive retinopathy. PERG abnormalities were detected in 96.8% of hypertensive retinopathy patients and 79.5% of hypertensive patients with normal fundus. Conclusions PERG can objectively assess retinal dysfunction in hypertensive patients and may be considered a promising tool for early detection of hypertensive retinopathy.

O-EV003. Role of multifocal electroretinogram in assessment of early retinal dysfunction in hypertensive patients

Introduction . Hypertensive retinopathy is the second most common cause of retinopathy following diabetes, probably caused by retinal ischemia as a consequence of atherosclerotic irreversible changes of systemic hypertension. Non-uniform functional retinal abnormalities are difficult to detect by full-field ERG and needs the disease to reach advanced changes to be affected. mfERG offers an objective noninvasive and reliable method to measure retinal function. It allows simultaneous recording of local ERG responses from different parts of the retina. Also previous studies suggested that the abnormalities in retinal electrophysiological studies usually precede fundus signs of retinopathy as mfERG is affected early by the neurodegenerative process. our aim in this study was to investigate localized retinal dysfunction in hypertensive patients using multifocal electroretinogram (mfERG) and to assess its sensitivity as an early predictor for the development of retinopathy in hypertensive patients. Methods . Ninety-eight eyes were included in this case-control study. Twenty-eight eyes of healthy subjects served as a control group (group I). Seventy eyes belonged to patients with systemic hypertension assigned into two groups; group II including 39 eyes of hypertensive patients with normal fundus and group III including 31 eyes of patients with signs of hypertensive retinopathy. All participants were subjected to complete ophthalmic and electrophysiological examination using mfERG. N1 and P1 wave amplitudes and implicit times from the central hexagon and four concentric rings across the visual field were analyzed. Results . mfERG amplitudes were significantly reduced in hypertensive group with retinopathy than in controls. N1 amplitude was significantly reduced in the most eccentric ring in eyes of hypertensive patients with normal fundus. Conclusion . mfERG is a sensitive objective tool for assessment of retinal dysfunction in hypertensive patients. mfERG amplitude is a promising predictor for early development of retinopathy in systemic hypertension.

Role of multifocal electroretinogram in assessment of early retinal dysfunction in hypertensive patients.

To investigate localized retinal dysfunction in hypertensive patients using multifocal electroretinogram (mfERG) and to assess its sensitivity as an early predictor for the development of retinopathy in hypertensive patients. Ninety-eight eyes were included in this case-control study. Twenty-eight eyes of healthy subjects served as a control group (group I). Seventy eyes belonged to patients with systemic hypertension assigned into two groups; group II including 39 eyes of hypertensive patients with normal fundus and group III including 31 eyes of patients with signs of hypertensive retinopathy. All participants were subjected to complete ophthalmic and electrophysiological examination using mfERG. N1 and P1 wave amplitudes and implicit times from the central hexagon and four concentric rings across the visual field were analyzed. mfERG amplitudes were significantly reduced in hypertensive group with retinopathy than in controls. N1 amplitude was significantly reduced in the most eccentric ring in eyes of hypertensive patients with normal fundus. mfERG is a sensitive objective tool for assessment of retinal dysfunction in hypertensive patients. mfERG amplitude is a promising predictor for early development of retinopathy in systemic hypertension.

Retinal Vascular Signs and Cerebrovascular Diseases.

Cerebrovascular disease (CeVD), including stroke, is a leading cause of death globally. The retina is an extension of the cerebrum, sharing embryological and vascular pathways. The association between different retinal signs and CeVD has been extensively evaluated. In this review, we summarize recent studies which have examined this association. We searched 6 databases through July 2019 for studies evaluating the link between retinal vascular signs and diseases with CeVD. CeVD was classified into 2 groups: clinical CeVD (including clinical stroke, silent cerebral infarction, cerebral hemorrhage, and stroke mortality), and sub-clinical CeVD (including MRI-defined lacunar infarct and white matter lesions [WMLs]). Retinal vascular signs were classified into 3 groups: classic hypertensive retinopathy (including retinal microaneurysms, retinal microhemorrhage, focal/generalized arteriolar narrowing, cotton-wool spots, and arteriovenous nicking), clinical retinal diseases (including diabetic retinopathy [DR], age-related macular degeneration [AMD], retinal vein occlusion, retinal artery occlusion [RAO], and retinal emboli), and retinal vascular imaging measures (including retinal vessel diameter and geometry). We also examined emerging retinal vascular imaging measures and the use of artificial intelligence (AI) deep learning (DL) techniques. Hypertensive retinopathy signs were consistently associated with clinical CeVD and subclinical CeVD subtypes including subclinical cerebral large artery infarction, lacunar infarction, and WMLs. Some clinical retinal diseases such as DR, retinal arterial and venous occlusion, and transient monocular vision loss are consistently associated with clinical CeVD. There is an increased risk of recurrent stroke immediately after RAO. Less consistent associations are seen with AMD. Retinal vascular imaging using computer assisted, semi-automated software to measure retinal vascular caliber and other parameters (tortuosity, fractal dimension, and branching angle) has shown strong associations to clinical and subclinical CeVD. Other new retinal vascular imaging techniques (dynamic retinal vessel analysis, adaptive optics, and optical coherence tomography angiography) are emerging technologies in this field. Application of AI-DL is expected to detect subclinical retinal changes and discrete retinal features in predicting systemic conditions including CeVD. There is extensive and increasing evidence that a range of retinal vascular signs and disease are closely linked to CeVD, including subclinical and clinical CeVD. New technology including AI-DL will allow further translation to clinical utilization.

Evaluation of the retinal vasculature of patients with branch retinal vein occlusion using optical coherence tomography angiography.

To evaluate vascular density in super-ficial and deep capillary plexuses of the retina, measured using optical coherence tomography angiography in patients with branch retinal vein occlusion. Affected eyes were compared with the contralateral eye of the same patient and both were compared with normal eyes. A cross-sectional study including 16 previously untreated patients with branch retinal vein occlusion. Patients with poor quality examinations, bilateral disease, high refractive error, or any other retinal or choroidal disease were excluded. A total of 31 patients without eye disease were also selected as a comparison group. All participants underwent five optical coherence tomography angiographies, and only those with at least two good quality examinations were selected. The Kruskal-Wallis, Wilcoxon signed-rank, and Mann-Whitney U tests were used for the statistical analysis. Vascular density was lower in affected eyes compared with contralateral eyes: whole density (p=0.020 for capillary plexuses superficial; p=0.049 for deep capillary plexuses) and parafoveal density (p=0.020 for capillary plexuses superficial; p=0.011 for deep capillary plexuses). Vascular density was also lower in affected eyes compared with normal eyes: whole density (p<0.001 for capillary plexuses superficial and deep) and parafoveal density (p<0.001 for capillary plexuses superficial and deep). Whole density (p=0.001 for capillary plexuses superficial and deep) and parafoveal density (p=0.001 for capillary plexuses superficial; p<0.001 for deep capillary plexuses) were both lower in the contralateral eyes compared with normal eyes. Following adjustment for arterial hypertension, this difference was no longer observed. Vascular density in capillary plexuses and deep capillary plexuses was lower in the eyes affected by branch retinal vein occlusion. Furthermore, the lower vascular density noted in the contralateral eyes indicates that changes most likely occurred in these eyes prior to the appearance of any clinically detectable alterations, reflecting the early signs of hypertensive retinopathy.

Image processing-based model for tortuosity measurement of retinal blood vessels

Purpose: The study of retinal blood vessel morphology is of great importance in retinal image analysis. The retinal blood vessels have a number of distinct features such as width, diameter, tortuosity, etc. In this paper, a method is proposed to measure the tortuosity of retinal blood vessels obtained from retinal fundus images. Tortuosity is a situation in which blood vessels become tortuous, that is, curved or non-smooth. It is one of the earliest changes that occur in blood vessels in some retinal diseases. Hence, its detection at an early stage can prevent the progression of retinal diseases such as diabetic retinopathy, hypertensive retinopathy, retinopathy of prematurity, etc. The present study focuses on the measurement of retinal blood vessel tortuosity for the analysis of hypertensive retinopathy. Hypertensive retinopathy is a condition in which the retinal vessels undergo changes and become tortuous due to long term high blood pressure. Early recognition of hypertensive retinopathy signs remains an important step in determining the target-organ damage and risk assessment of hypertensive patients. Hence, this paper attempts to estimate tortuosity using image-processing techniques that have been tested on artery and vein segments of retinal images.&#x0D; Design: Image processing-based model designed to measure blood vessel tortuosity.&#x0D; Methods: In this paper, a novel image processing-based model is proposed for tortuosity measurement. This parameter will be helpful for analyzing hypertensive retinopathy. To test the eff ectiveness of the system in determining tortuosity, the method is first applied on a set of synthetically generated blood vessels. Then, the method is repeated on blood vessel (both artery and vein) segments extracted from retinal images collected from publicly available databases and on images collected from a local eye hospital. The blood vessel segment images that are used in the method are binary images where blood vessels are represented by white pixels (foreground), while black pixels represent the background. Vessels are then classified into normal, moderately tortuous, and severely tortuous by following the analysis performed on the images in the Retinal Vessel Tortuosity Data Set (RET-TORT) obtained from BioIm Lab, Laboratory of Biomedical Imaging (Padova, Italy). This database consists of 30 artery segments and 30 vein segments, which were manually ordered on the basis of increasing tortuosity by Dr. S. Piermarocchi, a retinal specialist belonging to the Department of Ophthalmology of the University of Padova (Italy). The artery and vein segments with the fewest number of turns are given a low tortuosity ranking, while those with the greatest number of turns are given a high tortuosity ranking by the expert. Based on this concept, our proposed method defines retinal image segments as normal when they present the fewest number of twists/turns, moderately tortuous when they present more twists/turns than normal but fewer than severely tortuous vessels, and severely tortuous when they present a greater number of twists/turns than moderately tortuous vessels. On implementing our image processing-based method on binary blood vessel segment images that are represented by white pixels, it is found that the vessel pixel (white pixels) count increases with increasing vessel tortuosity. That is, for normal blood vessels, the white pixel count is less compared to moderately tortuous and severely tortuous vessels. It should be noted that the images obtained from the different databases and from the local hospital for this experiment are not hypertensive retinopathy images. Instead, they are mostly normal eye images and very few of them show tortuous blood vessels.&#x0D; Results: The results of the synthetically generated vessel segment images from the baseline for the evaluation of retinal blood vessel tortuosity. The proposed method is then applied on the retinal vessel segments that are obtained from the DRIVE and HRF databases, respectively. Finally, to evaluate the capability of the proposed method in determining the tortuosity level of the blood vessels, the method is tested with a standard tortuous database, namely, the RET-TORT database. The results are then compared with the tortuosity level mentioned in the database. It was found that our method is able to classify blood vessel images as normal, moderately tortuous, and severely tortuous, with results closely matching the clinical ordering provided by the expert in the RET-TORT database. Subjective evaluation was also performed by research scholars and postgraduate students to cross-validate the results.&#x0D; Conclusion: The close correlation between the tortuosity evaluation using the proposed method and the clinical ordering of retinal vessels as provided by the retinal specialist in the RET-TORT database shows that, although simple, this method can evaluate the tortuosity of vessel segments effectively.&#x0D;

Microalbuminuria and Retinopathy among Hypertensive Nondiabetic Patients at a Large Public Outpatient Clinic in Southwestern Uganda.

Background Routine testing of microalbuminuria and retinopathy is not done among patients with high blood pressure in resource-limited settings. We determined the prevalence of microalbuminuria and retinopathy and their risk factors among hypertensive patients at a large hospital in western Uganda. Methods We consecutively recruited nondiabetic patients with hypertension at the outpatients' clinic over a period of 3 months. Spot urine samples were tested for urine albumin. Direct fundoscopy was done to assess retinal vasculature and optic disc for signs of hypertensive retinopathy. Logistic regression was done with retinopathy and microalbuminuria as primary outcomes. ResultsWe enrolled 334 patients and, of these, 208 (62.3%) were females, with median age of 55 years (range: 25–90). The prevalence of microalbuminuria was 59.3% (95% CI: 50.1–72.2) and that of retinopathy was 66.8% (95% CI: 58.6–76.5). The independent correlates of retinopathy and microalbuminuria were systolic blood pressure (SBP) > 140 mmHg (OR = 2.76, 95% CI: 1.29–5.93) and treatment with beta-blockers (OR = 2.16, 95% CI: 1.05–4.44). Use of ACEIs was unrelated to the study outcomes. ConclusionThe prevalence of retinopathy and microalbuminuria is high. Clinicians should aim for better control of blood pressure and routinely perform fundoscopy and urine albumin, especially for patients with poorly controlled blood pressure.

Corkscrewing of retinal arterioles leading to diagnosis of coarctation of aorta

Coarctation of aorta (CoA) usually leads to elevation of blood pressure above the site of obstruction and this elevated blood pressure probably gets transferred and is reflected in the retinal arterioles producing certain signs of hypertensive retinopathy. Fundus examination helps in differentiating hypertension due to CoA from other causes of juvenile hypertension, as corkscrewing of retinal arterioles is seen only in CoA but not in other conditions. A 16 year hypertensive male who was on antihypertensive treatment presented for routine checkup. On examination his visual acuity was 6/6 in both eyes. Funduscopy of both eyes revealed a normal optic disc with generalised narrowing of arterioles and broadened light reflex. The arterioles showed corkscrew tortuosity (U shaped arterioles). Based on the fundus findings, CoA was suspected and the patient was referred for cardiac evaluation. Echocardiogram revealed post ductal CoA. In juvenile hypertension, careful examination of the fundus can provide a clue to the systemic diagnosis and this case highlights the importance of ophthalmoscopic examination in diagnosing a potentially fatal systemic disease.

Hypertension and the eye.

Hypertension is the primary risk factor for cardiovascular disease and mortality that consists a major public health issue worldwide. Hypertension triggers a series of pathophysiological ocular modifications affecting significantly the retinal, choroidal, and optic nerve circulations that result in a range of ocular effects.The retina is the only place in the body where microvasculature can be directly inspected, providing valuable information on hypertension related systemic risks.The aim of this review is to provide an update on latest advances regarding the detection and significance of hypertension related eye signs. It's been shown that measurable retinal microvascular changes may precede progression of systemic microvascular disease.Last years, there are emerging advances in the field retinal imaging and computer software analysis that have enabled the objective and accurate assessment of retinal vascular caliber, while in association with latest epidemiological studies several other retinal vascular features have been recognized, such as vascular length-to-diameter ratio, and wall-to-lumen ratio that may also be associated to hypertension.Additionally, recent genetic studies have provided some insight to vascular pathophysiological processes having correlated new chromosome's loci to hypertensive retinopathy signs. Assessment of hypertensive retinopathy signs may convey additional prognostic information on the risk of end-organ damage and may alert for urgent systemic management or even preventive systemic therapies. Further development of retinal vascular imaging and computerized system may provide a significant tool to improve the diagnosis, prognosis, and management of hypertension in clinical practice.

Hypertension-related eye abnormalities and the risk of stroke.

Many studies have shown that hypertensive ocular funduscopic abnormalities are clearly related to stroke, even after controlling for blood pressure and other vascular risk factors. Retinal abnormalities indicative of a breakdown of the blood-retina barrier confer a greater increase in risk for stroke than sclerotic retinal changes. Similar retinal changes also have a positive relationship to stroke mortality. In addition, hypertensive ocular fundus abnormalities are reported to be associated with an increased risk for cognitive impairment, cerebral atrophy, progression of magnetic resonance imaging-defined white matter lesions, and subclinical infarction. Recent advances in fundus photography allow for improved accuracy and consistency in interpretation of funduscopic lesions, and improve the feasibility of screening for these abnormalities in at-risk patient populations. Evaluating the ocular fundus for signs of hypertensive retinopathy, in combination with an assessment of the presence or absence of other known vascular risk factors, may allow clinicians to further individualize a risk profile for stroke to each individual patient, thus permitting more accurate risk stratification and, potentially, guiding treatment strategies.

Ocular Manifestations of Systemic Diseases: The Eyes are the Windows of the Body

An ocular manifestation of a systemic disease is an eye condition that directly or indirectly results from a disease process originating from another part of the body. There are many diseases known to cause ocular or visual changes as a result of systemic disease. Diabetes, for example, is the leading cause of new cases of blindness in those aged 20-74, with ocular manifestations such as diabetic retinopathy and macular edema affecting up to 80% of those who have had the disease for 15 years or more. Other diseases such as acquired immunodeficiency syndrome (AIDS) and hypertension are commonly found to have associated ocular symptoms. Physicians need to consider that systemic disease can involve the eyes and it is important for ophthalmologists to understand that they may be the first to suggest a diagnosis due to underlying systemic disease. According to the quote “The eyes are the windows of the soul”, ophthalmologists should view the eyes as not only windows of the soul but also a window to the physical state of the entire body. Systemic hypertension is a major risk factor for the development of retinal vascular diseases including hypertensive retinopathy, retinal vein or artery occlusion, and embolic events. High blood pressure also increases the risk for the development and progression of diabetic retinopathy. Signs of hypertensive retinopathy are predictive of target-organ damage including cardiovascular and cerebrovascular diseases [1]. High blood pressure affects the heart, kidney, brain, large arteries, and also the eyes. Retinal, choroidal, and optic nerve circulations undergo pathophysiological changes resulting in clinical signs referred to as hypertensive retinopathy, hypertensive choroidopathy, and hypertensive optic neuropathy. Systemic hypertension also increases the risk for the development of retinal vein and artery occlusion, retinal-arteriolar emboli, and diabetic retinopathy. Diabetic retinopathy is one of the common causes of blindness. It is an ocular manifestation of diabetes, which affects up to 80 percent of all patients who have had diabetes for 20 years or more. Diabetic macular edema is the most common cause of visual dimness in patients with diabetic retinopathy. Dr. Lee will discuss the challenges and current treatments to prevent the visual disturbance related to diabetic macular edema [2]. Systemic lupus erythematosus (SLE) is an autoimmune disease in which the body’s immune system mistakenly attacks healthy tissue in many parts of the body. SLE is a potentially life-threatening multisystem disease that is commonly associated with ocular manifestations. The purpose of this review is to outline the ocular manifestations of SLE and treatments [3]. Ocular complications have been reported in up to one-third of patients with SLE. Ocular manifestations can be associated with significant morbidity and eye issues may play a role as a marker for systemic disease activity. Keratoconjunctivitis sicca is the most common ocular problem in patients with SLE. When ophthalmologists see patients complaining of dry eye symptoms, determining the underlying reason as to why these patients are suffering from dry eye symptoms is important. The hypo-secretion of tears is one cause of dry eye symptoms.

Rare case of exudative retinal detachment in Normotensive HELLP syndrome: A Case Report

HELLP syndrome (hemolysis, elevated liver enzymes and low platelets) is defined as a severe form of preeclampsia which leads to maternal, fetal morbidities and sometimes even death. HELLP syndrome usually occurs in severe preeclampsia; but sometimes it may present with atypical clinical features. Bilateral, serous, non-rhegmatogenous retinal detachment is a rare complication in severe hypertensive disorders of pregnancy, in most of the cases serous detachment is associated with development of hypertensive retinopathy. Here we report a rare case of 24-year-old female who presented at 36 weeks of pregnancy with headache, and diminution of vision in both eyes. Two days after admission a proteinuria of 440 mg/24 h was detected. She had platelet count of 70,000/ cc 3 and elevated liver enzymes. However the patient had normal blood pressure. Her serum was creatinine normal. The patient required a platelet transfusion. Fundus examination revealed exudative retinal detachment involving inferior quadrant. No signs of hypertensive retinopathy were noted. Prompt recovery with good visual acuity occurred after the pregnancy ended.

The resolution of central variant of posterior reversible encephalopathy syndrome.

A 44-year-old female, with a history of severe hypertension, presented with subacute onset of headache and visual deterioration. The general and neurological examination was unremarkable. The ophthalmologic examination showed signs of chronic hypertensive retinopathy. Blood pressure was 230/130 mm Hg. Initial brain computed tomography (CT) scan revealed the presence of hypodensity in the pons, cerebellum, and thalamus (Figure 1A and ​andB).B). On brain magnetic resonance imaging (MRI), the lesions were consistent with vasogenic edema involving the brain stem, cerebellum, thalamus, and basal ganglia (Figure 1C-​-J).J). The remaining investigation (hemogram, biochemical, echocardiogram, renal and suprarenal echography, and lumbar puncture) was unremarkable. The blood pressure was lowered to 150 to 140 mm Hg and the diastolic blood pressure to 110 to 100 mm Hg with amlodipine, Ramipril, and furosemide. After 2 weeks, she was completely asymptomatic. The repeated MRI of the brain revealed complete resolution of the previous lesions (Figure 2). Isolated involvement of the brain stem and cerebellum is an extremely rare central variant of posterior reversible encephalopathy syndrome (PRES).1 The combination of severe hypertension, clinical–radiological dissociation, and brain MRI with findings compatible with vasogenic edema is typical of the central variant of PRES.1,2 This triad should promptly guide the treatment toward blood pressure normalization and avoid unnecessary investigations. Figure 1. Initial brain computed tomography (CT) showing hypodensity in the pons, cerebellum, and thalamus (A and B), axial brain magnetic resonance imaging (MRI) showing hyperintensity in the pons, midbrain, middle cerebellar peduncles, and thalamus on fluid-attenuated ... Figure 2. Follow-up brain magnetic resonance imaging (MRI) showing complete resolution of the cerebral edema on fluid-attenuated inversion recovery (FLAIR; A-D) and coronal T2-weighted (E) and normal sign on DWI-weighted (F), ADC map (G), and T1-coronal T1-weighted ...