Fundus lesions in malignant hypertension. VI. Hypertensive choroidopathy

Experimental renovascular malignant arterial hypertension was produced, by modified Goldblatt's procedures, in 60 rhesus monkeys, and hypertensive fundus changes were studied in detail (by serial ophthalmoscopy and fluorescein fundus angiography in all monkeys on a long-term follow-up, and pathologically in 29 eyes). In hypertensive choroidopathy, retinal pigment epithelial (RPE) lesions and serous retinal detachment (RD) were the classic ophthalmoscopic lesions, whereas fluorescein fundus angiography and histopathologic studies revealed marked abnormalities in the choroidal vascular bed, in addition to the changes in the RPE. The RPE lesions could be subdivided into initial acute focal lesions (due to focal RPE infarction), and degenerative lesions, which developed later and were progressive in nature, maximally involving the macular and peripheral regions of the fundus. The RD developed most commonly in the posterior pole and infrequently involved the peripheral retina. The choroidal vascular bed showed impaired circulation and extensive occlusive and ischemic changes. These studies revealed that hypertensive choroidopathy is as important a fundus change as hypertensive retinopathy. The pathogenesis of hypertensive choroidopathy is discussed in detail; the evidence indicates that it is due to choroidal ischemia, and that hypertensive choroidopathy and retinopathy are two independent and unrelated manifestations of renovascular malignant hypertension.     

Fundus lesions in malignant hypertension. V. Hypertensive optic neuropathy

We produced experimental renovascular arterial hypertension in 57 rhesus monkeys by modified Goldblatt's procedures. Hypertensive fundus changes were studied in detail by serial ophthalmoscopy and fluorescein fundus angiography in all animals on a long-term follow-up, and pathologically in 23 eyes. Initial evidence of hypertensive optic neuropathy was optic disc edema which developed at the median blood pressure (BP) of 190 mmHg (normal BP, 120 mmHg). On follow-up, mild to marked pallor of the optic disc developed. The optic disc changes were correlated with BP and other fundus changes. Pathogenesis of hypertensive optic neuropathy, which has been highly controversial so far, is discussed at length in the light of the findings of the present study and other recent evidence. All the available clinical and pathologic findings in the present study indicate that hypertensive optic neuropathy represents a form of anterior ischemic optic neuropathy, and that hypertensive optic neuropathy is a distinct entity. A caution is given against a precipitous reduction of BP in patients with hypertensive optic neuropathy because that may cause complete, permanent blindness.     

Fundus lesions in malignant hypertension. IV. Focal intraretinal periarteriolar transudates

Experimental renovascular malignant arterial hypertension was produced in 57 rhesus monkeys by a modified Goldblatt's procedure and their eyes were studied by serial ophthalmoscopy, by stereoscopic color fundus photography, and by fluorescein fundus angiography over a period of months or years. A very common, and one of the earliest, lesions in hypertensive retinopathy was focal intraretinal periarteriolar transudates (FIPTs). In the past, FIPTs have been described erroneously as "cotton-wool spots." The two types of lesions differ very much in shape, size, color, location, fluorescein fundus angiographic pattern, resolution pattern, life cycle, and pathogenesis. FIPTs, on ophthalmoscopy, usually are pinpoint to pinhead size, round or oval, dull white in color, and situated in deeper layers of the retina and beside the major retinal arteries and their main branches. On fluorescein angiography, FIPTs show multiple punctate foci of fluorescein leakage from dilated precapillary retinal arterioles, and there is no focal retinal capillary obliteration. They usually last for two to three weeks, and on resolution leave no ophthalmoscopic, angiographic, or microvascular abnormality. Cotton-wool spots are seen in a variety of retinopathies; FIPTs, however, are a specific retinal lesion of malignant arterial hypertension only. They develop due to breakdown of blood-retinal barrier in pre-capillary retinal arterioles, due to dilatation of the arterioles from failure of autoregulation (caused by severe rise of blood pressure).     

Fundus changes in pregnancy induced hypertension

AIM: To determine the prevalence of retinal changes in pregnancy induced hypertension (PIH) and any association between the retinal changes and blood pressure, proteinuria, and severity of the disease. METHODS: All the patients admitted with diagnosis of PIH were included in this study. Age, race, gravida, gestation period, blood pressure, and proteinuria were noted from the case records. After taking history for any eye symptoms, fundus examination was done after dilating the pupils with direct ophthalmoscope in the ward itself. All the findings were noted on a data sheet, and were analyzed using SPSS programme. RESULTS: A total of 78 patients of PIH were examined. Majority (75.6%) were Malays. The mean age of patients was 30.2 years (range 21-45 years). The gestation period ranged from 25 weeks to 41 weeks; 34 (43.5%) were primi gravida. Thirty (38.4%) patients had mild preeclampsia, 46 (59%) had severe preeclampsia and 2 (2.5%) had eclampsia. Retinal changes (hypertensive retinopathy) were noted in 46 (59%) patients --- grade I in 41 (52.6%) and grade II in 5 (6.4%). Haemorrhages or exudates or retinal detachment were not seen in any patient. There was statistically significant positive association of retinal changes and blood pressure (P =0.001), proteinuria (P =0.018) and severity of the PIH (P =0.024). CONCLUSION: Retinal changes (grade I and II hypertensive retinopathy) were seen in 59% of patients with PIH and they were significantly associated with blood pressure, proteinuria and severity of the disease. Fundus examination helps in assessing the severity of PIH.     

Fundus fluorescein angiography in fundus flavimaculatus and Stargardts disease.

Three siblings who had fundus flavimaculatus and two patients who had Stargardts disease were studied by means of fundus fluorescein angiography. The angiograms revealed in all cases an abolished visibility of the chorioidal circulation. New flecks are usually non-fluorescent. Later on, hyperfluorescent areas are seen at identical places both in the preretinal and retinal phases, strongly indicating a window effect of the retinal layer. The missing chorioidal flush is probably due to a blocking effect of the emitting and exciting light. Some of the retinal flecks may fade away, leaving corresponding areas of hyperfluorescence that usually persist. In some cases, however, a previous fluorescent area may become non-fluorescent. The similar angiographic picture may indicate that fundus flavimaculatus and Stargardts disease are different expressions of the same disease.     

The interpretation of systemic arterial blood pressure. Part III: hypertension retinopathy.

Systemic blood pressure is a vital sign and fundamental variable and as such the areas of its involvement in all individuals are indeed multifaceted. The purpose of this paper is to discuss the interpretation of systemic blood pressure readings as they specifically relate to a detailed analysis of hypertensive retinopathy.     

Macular lesions in malignant arterial hypertension

We produced experimental renovascular malignant arterial hypertension by a modified Goldblatt's procedure in 60 rhesus monkeys (25 one-kidney model and 35 two-kidney model), and studied various macular lesions by detailed serial ophthalmoscopy, and stereoscopic color fundus photography and fluorescein fundus angiography on a long-term follow-up. The various lesions which developed in the macular region included retinal edema, cystic retinal changes, serous retinal detachment, retinal pigment epithelial changes (initially acute focal and later degenerative lesions), and lipid deposits. In addition to these, the usual retinal lesions associated with hypertensive retinopathy, e.g., focal intraretinal periarteriolar transudates, cotton-wool spots and retinal hemorrhages, were also frequently seen in the macular retina. Findings on the various lesions are described in detail, and the pathogenesis of macular edema in malignant arterial hypertension is discussed.     

原发性高血压病的眼底病变

原发性高血压眼底病变是一种常见的与血压升高密切相关的眼部体征,分为视网膜血管病变和视网膜血管以外病变.视网膜血管病变包括动脉痉挛、动脉硬化、动静脉交叉处的Salus征、Gunn现象等 视网膜血管外病变包括视网膜水肿混浊、出血、硬性渗出、棉绒状斑,脉络膜Elschnig斑、Segrist条纹及视乳头水肿等.视网膜动脉硬化发生在动脉痉挛持续一段时间之后,见于缓进型高血压第二、三期.视网膜血管以外病变,由动脉的强烈痉挛引起,见于高血压急进型或缓进型病情突然恶化之际.发生视网膜血管以外病变,提示心、肾、脑等全身重要器官已有严重的器质性损害和功能衰竭.特别是视乳头水肿一旦出现,则提示患者生命预后极为严峻.     

Fundus albipunctatus: A clinical study of the fundus lesions,the physiologic deficit,and the vitamin a metabolism

Two unrelated patients with fundus albipunctatus, each the product of a consanguinous marriage, were studied with reference to their fundus lesions, their physiologic deficit and their vitamin A metabolism.Both patients showed albipunctate lesions that appeared deep to vessels and either blocked fluorescein or were invisible on angiography. Some of the lesions changed during a 1–2 year observation period. In one patient the lesions showeds a radial arrangement in the fundus. Both patients showed greatly retarded dark adaptation, measured subjectively or with the electroretinogram. Cone as well as rod dysfunction was involved, and subtle abnormalities of the visual fields and of color vision were found. The a- and b-waves of the electroretinogram were both affected by the disease, suggesting an adaptation defect prior to generation of the a-wave. These findings are consistent with the observation of Carr, Ripps & Siegel (1974) that photopigment regeneration is retarded in this disease. Both patients showed normal blood levels of vitamin A, carotene, retinol binding protein, amino acids, proteins and lipoproteins. The administration of therapeutic levels of vitamin A parenterally and orally had no effect on the rate of dark adaptation or the fundus lesions.This study supports the view that fundus albipunctatus is a stationary recessive disorder which can be defined physiologically by a slow rate of dark adaptation and visual pigment regeneration, and which is clinically separable from progressive dystrophies such as retinitis punctata albescens. The significance of the albipunctate fundus lesions remains unclear. If vitamin A metabolism is involved in fundus albipunctatus, the involvement must be at a local level.     

Fundus changes in histologically confirmed sarcoidosis.

We reviewed the clinical features, natural history and visual prognosis of 26 patients with histologically confirmed sarcoidosis. Compatible chest x-ray changes were found in 75% of patients. Periphlebitis was the commonest fundus feature. Disc changes were seen in a substantial number of patients, and the condition can present as unilateral disc oedema. The disease seems primarily to involve equatorial retinal veins, and occlusions of a hemisphere branch vein or central retinal vein did not occur. Changes in the subretinal pigment epithelium were noted in a substantial number of patients but did not produce visual morbidity, and these patients seemed to have less florid periphlebitis than others. The disease has a low visual morbidity unless neovascularisation develops; the treatment of this remains controversial.