By Adam H. Rogers, MD, and Jay S. Duker, MD (Auth.)
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28 An involuted peripheral sea fan visible as a white area of preretinal fibrosis occurring from autoinfarction. 57 Hypertensive Retinopathy Key Facts • Changes in retina, choroid, and optic nerve occurring with elevation of systemic arterial hypertension • Most cases are chronic with changes in the retinal vasculature • Occurs in about 15% of patients with hypertension • Bilateral • Men and women equally affected • No racial predilection Clinical Findings SECTION 3 • Vascular Obstructions • • • • • • • • • • Arteriovenous nicking at crossing of retinal arteriole and vein Retinal arteriolar narrowing (most common finding) Cotton wool spots Nerve fiber layer hemorrhage Microaneurysms Macular edema Exudation Elschnig spots Neurosensory detachment Disc edema Ancillary Testing • Measurement of blood pressure Differential Diagnosis • • • • • • Diabetic retinopathy Radiation retinopathy Vogt–Koyanagi–Harada disease Venous occlusive disease Ocular ischemic syndrome Hyperviscosity syndromes Treatment • Refer to primary care physician for treatment of chronic systemic arterial hypertension • Immediate referral to emergency department for cases of acute systemic arterial hypertension Prognosis • Correction of blood pressure will lead to the resolution of acute clinical findings (disc edema, macular edema, and neurosensory detachment) within 2 weeks • More chronic findings of arteriolar narrowing and arteriovenous nicking rarely resolve • Vision loss is rare unless chronic ischemia to the macula persists 58 Fig.
Hypertensive Retinopathy Fig. 30 Severe hypertensive retinopathy in a woman with advanced renal failure. Fig. 31 Multiple cotton wool spots and narrowing of arterioles in an eye with hypertensive retinopathy. 59 Hypertensive Retinopathy (Continued) SECTION 3 • Vascular Obstructions A B Fig. 32 (A) Right and (B) left eye of a woman with pregnancy-induced hypertension from pre-eclampsia. Focal yellow choroidal lesions are visible superior to the optic nerve in the right and along the superior temporal arcade in the left eye.
41 Central Retinal Artery Obstruction Key Facts • Abrupt, painless loss of vision from diminished flow through the central retinal artery • Occur at the central retinal artery or the ophthalmic artery • Most common in elderly adults in the seventh decade • Occurs in 1 in 10 000 • Men affected more than women • Bilateral in 1–2% of cases • Thrombus at the level of the lamina cribrosa is the most common cause • Embolus seen in about 20% of eyes • Giant cell arteritis occurs in 1–2% of cases • Dissecting aneurysm is a rare cause • In younger adults, central retinal artery obstruction may occur from migraine, coagulation disorders, hemoglobinopathies, or optic disc drusen SECTION 3 • Vascular Obstructions Clinical Findings • Decreased visual acuity • Relative afferent pupillary defect • Acute clinical findings: • retinal whitening focused in the macula • cherry red spot at the fovea • narrow retinal arteries • visible red blood cell columns in the arteries (boxcarring) • patent cilioretinal artery (25% of eyes) • neovascularization of the iris (20%) • Chronic clinical findings: • re-establishment of arterial circulation • loss of retinal whitening • narrowing of retinal arterioles • absence of visible nerve fiber layer • optic nerve pallor • optic disc collaterals • neovascular glaucoma • neovascularization of optic disc (2% of eyes) Ancillary Testing • Fluorescein angiography shows delay in retinal arteriolar filling in the acute setting • Delayed choroidal filling implies ophthalmic artery obstruction or carotid artery stenosis • The angiogram will revert to normal with re-establishment of arteriolar circulation • Electroretinogram (ERG) with decreased b wave and normal a wave • With improved retinal blood flow, the ERG may normalize • Visual fields may show a residual temporal island • In the presence of a patent cilioretinal artery, a small central island may remain • Carotid ultrasound to evaluate for carotid artery disease • Transthoracic or transesophageal cardiac ultrasound to evaluate for valvular disease or embolic source, especially in patients younger than 50 • Erythrocyte sedimentation rate for giant cell arteritis Differential Diagnosis • • • • 42 Commotio retina Multiple branch retinal artery obstructions Viral retinitis Cilioretinal artery obstruction A B Fig.