Hypertensive Retinopathy in Malignant Hypertension. Hypertensive Encephalopathy.
Hypertensive Retinopathy in Malignant Hypertension. Hypertensive Encephalopathy.
In this video we are going to see the ophthalmoscopic characteristics of Hypertensive Retinopathy associated with Malignant Hypertension.
🟢 This is the case of a 43-year-old male patient with Hypertensive Retinopathy, Malignant Arterial Hypertension and Hypertensive Encephalopathy.
👤 J.R. Fontenla, MD-PhD. Medical Consultant in Ophthalmology 🏨 Hospital Clinic of Barcelona 👁 / @visualsystem Professor of Ophthalmology 🏛 University of Barcelona 📩 [email protected] 🌍 Instagram: @visus.formacion
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Content
1.52 -> In this video we are going to see
the ophthalmoscopic characteristics
6.08 -> of Retinopathy associated with Malignant
Hypertension. This is the case of a 43
14.08 -> year old male patient with Aalignant Arterial
Aypertension and Hypertensive Encephalopathy.
26.08 -> Optic disc swelling in arterial hypertension
will always be considered the highest degree of
33.52 -> hypertensive retinopathy, in whatever
classification we use. It is a marker of
41.44 -> severity and represents the ocular manifestation
of hypertensive encephalopathy. Without treatment,
50.96 -> the life expectancy of these patients
is 8 months. The mortality rate in the
58.64 -> first year amounts to 80 percent, at three
years it reaches 94 percent and it is 99
69.68 -> at five years. Only one percent of patients with
this condition will survive five years. This is
79.28 -> why the effective establishment of hypertension
treatment is a vital urgency in these cases.
92.32 -> Remember: optic d swelling is the ocular
marker of hypertensive encephalopathy.
105.28 -> Ophthalmoscopically in optic disc swelling
108.64 -> we see a decrease or disappearance of
the physiological optic disc excavation.
119.92 -> The sharp edges of the normal disk also disappear,
124.56 -> they are now blurred and it is difficult
to delineate the optic disc contour.
136 -> Simultaneously, due to edema, the margins
of the optic disc are also raised.
148.96 -> The neuroretinal ring appears
swollen and hemorrhagic.
158.08 -> And the edema and hemorrhages of the neuroretinal
ring diminish, or completely eliminate,
165.68 -> the vision of the course of the
vessels as they enter the optic disc.
175.68 -> Ophthalmoscopically hard exudates appear as
a small white or yellowish-white deposits
183.2 -> with sharp margins. They often appear
as if they are made of wax, shiny or
191.12 -> glittery. They can be arranged as single dots,
confluent patches, sheets, rings or crescents.
202.56 -> They are composed of lipoproteins, lipids
and protein material, such as fibrinogen
210.08 -> and albumin, that extravasate after
the inner blood-retinal barrier
215.52 -> is broken. They will be deposited, mainly,
in the outer plexiform layer of the retina.
228.56 -> Thus, in the pathogenesis of hard
exudates, we see a double origin.
235.6 -> First hard exudates are due to
increase its vascular permeability,
241.36 -> which allows fluid and lipoproteins to leak into
the retina. Subsequent resorption of the edema,
250.88 -> commonly results in the precipitation of the
lipid residues within the outer plexiform layer.
260.72 -> Secondly, the paralysis of the axoplasmic flow at
the level of the ganglion cells, whose axons form
267.28 -> the nerve fever layer of Henle, is also involved.
The stopped axoplasmic flow hinders the transport
276.16 -> and drainage of the waste substances, thus
favoring their accumulation in the Henle's layer.
290.24 -> The formation of the macular star is due to
the deposit of hard exudates around the macula,
298 -> adopting a characteristic
radial or star-shaped pattern.
307.28 -> The soft exudate, or cotton-wool spot, should
not be called exudate, because it is actually an
316.64 -> ischemic edema of the retinal nerve fiber layer,
and not an exudate. It represents an infarction of
328.16 -> the retinal nerve fiber layer, due to an occlusion
of a terminal arteriole due to arteriolonecrosis.
342.48 -> Remember that the cotton-wool spot represents
the ocular marker of the malignancy of arterial
350.08 -> hypertension. When the cotton-wool spot
appears, the parenchyma of the target
356.88 -> organs of hypertension (brain, heart,
kidney...) is suffering severe damage.
368.64 -> Splinter, or flame-shaped hemorrhages,
are a subset of retinal hemorrhages
375.2 -> which are located within the nerve fiber layer
of the retina. They have a directional value,
383.68 -> since they are oriented following the path of
the ganglion cell axons towards the optic disc.
395.84 -> Dot-and-blot hemorrhages are
found deeper in the retina
399.76 -> than flame-shaped hemorrhages,
or splinter hemorrhages.
405.2 -> Usually in this case, the blood collects in
the outer plexiform or inner nuclear layers.
412.56 -> Its configuration is due to retinal compression,
restricting hemorrhages to a specific place.
421.44 -> There are easiest to see in the peripheral
retina, where the nerve fiber layer is thinnest.
429.28 -> Dot hemorrhages are or resemble microaneurysms. We
must differentiate them, although sometimes it can
437.04 -> be difficult, and fluorescein angiography
may be necessary to distinguish them.
447.2 -> In this case we can see dilated,
thickened veins, with a greater caliber.
454.72 -> This is caused by the stagnation or
difficulty of passage of the venous
460.32 -> blood column at different levels. At the
level of the optic disc, due to edema,
467.52 -> and also at the level of pathological
arteriovenous crossings, Arteriovenous nicking.
479.12 -> We also see the relationship of the arteriovenous
caliber altered. This is due to the decrease in
486.88 -> the ratio between the caliber of the
artery and the caliber of the vein.
493.2 -> The causes are two: the increase in
the venous caliber, as we have seen,
499.44 -> and the decrease in the arteriolar caliber,
due to the vasoconstriction of the arteriole.
510.48 -> Arteriovenous nicking is the phenomenon
where an arteriole is seen crossing a venule,
516.24 -> which results in the compression of the vein
and alterations in the venous blood column.
523.76 -> it is thought that, since the arteriole and
venule share a common adventitia at the level
529.36 -> of the arteriovenous crossing, the arteriole's
thicker walls, and the greater pressure of
535.76 -> its blood column, push against the walls of
the venule, forcing the venule to collapse.
543.28 -> Other theories suggest that this results not from
compression from the arteriole but from sclerotic
550.24 -> thickening or glial cell proliferation
at the site where the two vessels cross.
562.08 -> Here we can see Bonnet's sign circumambulated,
which is made up of the following triad:
573.84 -> an arteriovenous nicking
581.52 -> associated, in the vicinity of the
crossing, with a cotton-wool spot
591.44 -> and retinal hemorrhages.
598.32 -> Here we can see the retinography of
the right eye of the clinical case.
612.24 -> And here you can also see his left eye.
Thank you so much for your attention.
