09/01/13

Ocular ef f ects of hy pertension

Official reprint from UpToDate www.uptodate.com 2013 UpToDate

Ocular effects of hypertension Author Norman M Kaplan, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Dec 2012. | This topic last updated: jul 18, 2012. INTRODUCTION A number of ocular abnormalities are directly or indirectly associated with hypertension [1,2]. These include some that are a direct consequence of elevated blood pressure, including hypertensive retinopathy, choroidopathy, and optic neuropathy. With other abnormalities, hypertension is a significant risk factor, including retinal vein and artery occlusion, retinal artery emboli, and diabetic retinopathy. In addition, hypertension may accelerate nonvascular eye disease, including age-related macular degeneration and glaucoma. OCULAR DISEASES DIRECTLY RELATED TO HYPERTENSION Fundoscopy should be part of the physical examination on every patient with newly diagnosed hypertension, since the retina is the only part of the vasculature that can be visualized non-invasively. Pupillary dilatation with a short-acting mydriatic (eg, tropicamide 1 percent) is almost always useful, since the mild changes are hard to quantify, even with retinal photography [3]. The most common ocular diseases directly related to hypertension are progressively increasing retinal microvascular changes, which are subsumed under the name "hypertensive retinopathy." Classically, the features are divided into four degrees and their morphological classification has been widely used [4]. However, a more pathophysiological division has been proposed and seems more logical [3]. This three-degree classification includes mild, moderate, and severe: Mild Retinal arteriolar narrowing related to vasospasm, arteriolar wall thickening or opacification, and arteriovenous nicking, referred to as nipping [3]. Moderate Hemorrhages, either flame or dot-shaped, cotton-wool spots, hard exudates, and microaneurysms (picture 1). Severe Some or all of the above, plus optic disc edema (picture 2A-B). The presence of papilledema mandates rapid lowering of the blood pressure. Generalized narrowing and nicking are related to current and previous blood pressure levels; by comparison, focal narrowing, hemorrhages, and exudates are related only to current blood pressure levels [5]. Retinal arterial narrowing, a predictor of the future development of hypertension, is linked to non-ocular systemic vascular diseases, particularly stroke [6,7]. Substantial evidence exists for the association with coronary heart disease, left ventricular remodeling, and kidney damage [8-11]. The presence of hypertensive retinopathy should serve as an additional stimulus to ensure adequate control of hypertension. With good control, retinopathy may regress, providing an easily obtained indicator of success [12]. HYPERTENSION AS A RISK FACTOR FOR OCULAR DISEASE Hypertension increases the risk of a number of ocular diseases. The most common is diabetic retinopathy, which is the most common cause of blindness in developed societies. In a multi-ethnic cohort in the United States, retinopathy was found in 33 percent of diabetics over age 40, 8 percent of whom had vision-threatening retinopathy [13]. Multiple factors may be involved in the
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Section Editor George L Bakris, MD

Deputy Editor John P Forman, MD, MSc

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Ocular ef f ects of hy pertension

added risk of hypertension to the development and progression of diabetic retinopathy, including increased endothelial damage [14]. Fortunately, good control of hypertension can reduce the threat of diabetic retinopathy, independent of control of hyperglycemia [15]. In the UK Prospective Diabetes study, the risk of retinopathy was reduced 10 percent for each 10 mmHg lower systolic blood pressure [15]. Limited evidence supports an additional protective effect of ACE inhibitors beyond their antihypertensive effect [16]. Other ocular diseases wherein hypertension serves as a risk factor include retinal venous and arterial occlusion, retinal emboli, retinal macroaneurysm, and anterior ischemic optic neuropathy [1]. OCULAR DISEASES WHEREIN HYPERTENSION MAY BE A RISK FACTOR The risk for two of the more common causes of vision loss, age-related macular degeneration and glaucoma, may be increased by the presence of systemic hypertension. Although cross sectional data support an association [17,18], the evidence is not conclusive. It should be noted that systemic hypotension, especially at night from excessive antihypertension therapy, has been shown to further reduce blood flow to the optic nerve, accentuating the damage of high intraocular pressure from glaucoma [19]. (See "Age-related macular degeneration: Epidemiology, etiology, and diagnosis" and "Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis".) SUMMARY The most common ocular diseases directly related to hypertension are progressively increasing retinal microvascular changes, which are subsumed under the name "hypertensive retinopathy." The three-degree classification includes mild, moderate, and severe disease. The presence of papilledema mandates rapid lowering of the blood pressure. (See 'Ocular diseases directly related to hypertension' above.) Hypertension increases the risk of a number of ocular diseases, with the most common being diabetic retinopathy. Other ocular diseases wherein hypertension serves as a risk factor include retinal venous and arterial occlusion, retinal emboli, retinal macroaneurysm, and anterior ischemic optic neuropathy. (See 'Hypertension as a risk factor for ocular disease' above.) The risk for two of the more common causes of vision loss, age-related macular degeneration and glaucoma, may be increased by the presence of systemic hypertension. (See 'Ocular diseases wherein hypertension may be a risk factor' above.)

Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Wong TY, Wong T, Mitchell P. The eye in hypertension. Lancet 2007; 369:425. 2. Gudmundsdottir H, Taarnhj NC, Strand AH, et al. Blood pressure development and hypertensive retinopathy: 20-year follow-up of middle-aged normotensive and hypertensive men. J Hum Hypertens 2010; 24:505. 3. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004; 351:2310. 4. Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: their course and prognosis. Am J Med Sci 1974; 268:336. 5. Sharrett AR, Hubbard LD, Cooper LS, et al. Retinal arteriolar diameters and elevated blood pressure: the Atherosclerosis Risk in Communities Study. Am J Epidemiol 1999; 150:263. 6. Wong TY, Klein R, Sharrett AR, et al. Retinal arteriolar diameter and risk for hypertension. Ann Intern Med 2004; 140:248. 7. Wong TY, Klein R, Couper DJ, et al. Retinal microvascular abnormalities and incident stroke: the Atherosclerosis Risk in Communities Study. Lancet 2001; 358:1134.
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8. Wong TY, Klein R, Sharrett AR, et al. Retinal arteriolar narrowing and risk of coronary heart disease in men and women. The Atherosclerosis Risk in Communities Study. JAMA 2002; 287:1153. 9. Cheung N, Bluemke DA, Klein R, et al. Retinal arteriolar narrowing and left ventricular remodeling: the multiethnic study of atherosclerosis. J Am Coll Cardiol 2007; 50:48. 10. Wong TY, Coresh J, Klein R, et al. Retinal microvascular abnormalities and renal dysfunction: the atherosclerosis risk in communities study. J Am Soc Nephrol 2004; 15:2469. 11. Shantha GP, Kumar AA, Bhaskar E, et al. Hypertensive retinal changes, a screening tool to predict microalbuminuria in hypertensive patients: a cross-sectional study. Nephrol Dial Transplant 2010; 25:1839. 12. Bock, KD. Regression of retinal vascular changes by antihypertensive therapy. Hypertens 1984; 6:158. 13. Wong TY, Klein R, Islam FM, et al. Diabetic retinopathy in a multi-ethnic cohort in the United States. Am J Ophthalmol 2006; 141:446. 14. Hsueh WA, Anderson PW. Hypertension, the endothelial cell, and the vascular complications of diabetes mellitus. Hypertension 1992; 20:253. 15. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998; 317:703. 16. Randomised placebo-controlled trial of lisinopril in normotensive patients with insulin-dependent diabetes and normoalbuminuria or microalbuminuria. The EUCLID Study Group. Lancet 1997; 349:1787. 17. Hyman L, Schachat AP, He Q, Leske MC. Hypertension, cardiovascular disease, and age-related macular degeneration. Age-Related Macular Degeneration Risk Factors Study Group. Arch Ophthalmol 2000; 118:351. 18. Mitchell P, Lee AJ, Rochtchina E, Wang JJ. Open-angle glaucoma and systemic hypertension: the blue mountains eye study. J Glaucoma 2004; 13:319. 19. Hayreh SS, Zimmerman MB, Podhajsky P, Alward WL. Nocturnal arterial hypotension and its role in optic nerve head and ocular ischemic disorders. Am J Ophthalmol 1994; 117:603. Topic 3859 Version 4.0
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