|Year : 1990 | Volume
| Issue : 4 | Page : 169-174
A correlative study of ophthalmoscopy and fluorescein angiography in systemic hypertension
Pradeep Jain1, Amod Gupta2, BK Sharma1
1 Department of Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh-160 012, India
2 Department of Opthalmology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
B K Sharma
Department of Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh-160 012
Source of Support: None, Conflict of Interest: None
This study correlates the fundus signs with the severity and signs of hypertension and evaluates the role of fluorescein angiography in detecting changes in the retinal and choroidal capillary bed in hypertension and defines its advantages over direct ophthalmoscopy. 37 hypertensives belonging to all grades of hypertension were studied. A thorough physical examination, hypertension work up, direct ophthalmoscopy and fluorescein angiography was done in all cases. A significant association was found between the presence of marked arteriolar narrowing and the presence of severe hypertension, left ventricular hypertrophy (LVH) and cardiomegaly. Patients having definite arterio-venous crossing changes and exudative retinopathy had a higher incidence of LVH and cardiomegaly. Renal functions and neurological signs in hypertension showed no correlation with the fundus signs. Capillary bed and choriodal abnormalities could be better studied on fluorescein angiography. Hard exudates were not visualized on fluorescein angiography. There was total resolution of exudative phenomenon on treatment.
|How to cite this article:|
Jain P, Gupta A, Sharma B K. A correlative study of ophthalmoscopy and fluorescein angiography in systemic hypertension. Indian J Ophthalmol 1990;38:169-74
| Introduction|| |
Keith, Wagner and Barker  put forward a classification for ophthalmoscopic changes in the fundus in patients of systemic hypertension which correlated directly with the degree of systemic hypertension and inversely with the prognosis for survival. Since then several studies have attempted to improve the correlation but none of them used fluorescein angiography as a tool of study and their assessment suffered from a subjective bias.
Novotony and Alvis  introduced fundus fluorescein angiography which documents the degree of perfusion in the retinal capillary bed. The integrity of the blood retinal barrier and the pathophysiology of the changes in the retina like haemorrhages, cotton wool spots and edema can be better understood by this means. It can also tell us about the choroidal vasculature, which has been shown experimentally to be affected in hypertension .
Since 1961, there have been few studies on fluorescein angiography in hypertension , but there is no study which correlates fundus fluorescein angiographic findings with the severity and signs of hypertension.
The present study correlates the fundus signs with the severity and signs of hypertension and evaluates the role of fluorescein angiography in detecting changes in the retinal and choroidal capillary beds in hypertension and defines its advantages over direct ophthalmoscopy.
| Material and methods|| |
A total of thirty seven patients attending the Hypertension Clinic and Eye Clinic as well as inpatients of the Nehru Hospital at Postgraduate Institute of Medical Education and Research, Chandigarh were studied. Hypertension was classified into three grades -WHO Tech. Rep.
1. Mild - Diastolic blood pressure 90-104 mm Hg (10 patients)
2. Moderate -Diastolic blood pressure 105-1 14 mm Hg (12 patients)
3. Severe- Diastolic blood pressure more than 115 mm Hg (including malignant hypertension) (15 patients) Thirty two age and sex matched controls were also studied. Patients with diabetes mellitus, vasculitis and collagen vascular disease were excluded.
Athorough physical examination and hypertension work up which included urine examination, haemogram, blood urea, serum creatinine, blood sugar, chest X-ray and electrocardiography(EKG) was carried out in all the cases. An intravenous urogram, angiogram and catecholamine estimation were done when indicated.
Fundus examination was done under full mydriasis and details of optic disc, retinal arteries and arterioles, veins, arteriovenous (A.V) ratio and crossing changes were recorded. Retinal changes like exudates - hard and soft, haemorrhages and vascular occlusions were recorded.
Fundus fluorescein angiography was studied by injecting 5ml of 10% sodium fluorescein in the antecubital vein and sequential fundus photographs were taken after a delay of nine seconds. The following observations were recorded : Optic disc, morphology of retinal vessels, blood flow and leakage of dye, closure pattern and leakage from capillary bed and any abnormal formation of new vessels, microaneurysms or A.V. Shunts, presence of exudates, haemorrhages, pigment epithelial defects and choroidal vasculature abnormalities were also noted. All patients were followed up for blood pressure behaviour and fundus signs over a period of six months. Repeat fluorescein angiography was done whenever possible.
| Results|| |
Of 37 cases, 29 were males and 8 females with majority of them belonging to an age group of 21-50 years (75.6%). 24(64.8%) patients had essential hypertension while 13(35.1%) had secondary hypertension due to renal parenchymal involvement (7 cases) renal artery stenosis (4 cases) and phaeochromocytoma (2 cases).
FUNDUS SIGNS vs SYSTEMIC SIGNS
I. ARTERIOLAR NARROWING vs SYSTEMIC SIGNS Out of 14 patients with marked arteriolar narrowing, 13 (92.8%) had severe hypertension, 9 (64.3%) had left ventricular hypertrophy (LVH) on EKG, 10 (71.4%) had cardiomegaly on chest x- ray and this association was found to be statistically significant (p 0.05). In contrast, out of 13 patients with mild and moderate arteriolar narrowing, only 1 patient (7.7%) had severe hypertension, 3(23%) had LVH and 4 (30%) had cardiomegaly. No significant association was observed between presence of central nervous system (CNS) signs or raised serum creatinine levels and the degree of arteriolar narrowing.
II. ARTERIOVENOUS CROSSING CHANGES vs SYTEMIC SIGNS
Out of 5 patients with definite arteriovenous crossing changes [Figure - 1] 3 (70%) had severe hypertension, 4 (80%) had LVH and all 5(100%) had cardiomegaly. 11 patients had early and moderate degree of arteriovenous crossing changes, 7 (63.6%) of these had severe hypertension, 5 (45.5%) had LVH and 7 (63.6%) had cardiomegaly. No statistically significant association was found between the presence of definite arteriovenous crossing changes and the presence of LVH or cardiomegaly (p 0.05). However, a significant association was found between the presence of arteriovenous crossing changes when grouped together (early, moderate and definite) and the presence of LVH (p 0.05) and cardiomegaly (p 0.01). Out of 16 patients with arteriovenous crossing changes, 4 (25%) had raised serum creatinine levels and this association was found to be statistically insignificant (p 0.05).
III.RETINAL BACKGROUND CHANGES vs SYSTEMIC SIGNS
Out of 9 patients having soft exudates [Figure - 2], 8 (88.8%) had severe hypertension, 7 (77.7%) had LVH and 8 (88.8%) had cardiomegaly. 6 patients had hard exudates [Figure - 2], out of these 5 (83.3%) had severe hypertension, 4 (666%) had LVH and cardiomegaly. The association between presence of retinal exudates and the presence of LVH, cardiomegaly and severity of hypertension was highly significant (p 0.01). 10 patients had haemorrhages in the retinal background, out of these 7 (70%) had severe hypertension and LVH. 8(80%) had cardiomegaly. 8 patients had r apilledema [Figure - 3], 7 out of these (R7.5%) had severe hypertension, 6 (75%) had LVH and cardiomegaly. Statistically, there was a significant association between the presence of papilledema and the presence of severe hypertension (p 0.01) and LVH (p 0.05; however, no such association was found with the presence of cardiomegaly (p 0.05). Correlating retinal background changes with the presence of raised serum creatinine levels or presence of CNS manifestations proved to be statistically insignificant (p 0.05).
FUNDUS SIGNS ON DIRECT OPHTHALMOSCOPY vs FLUORESCEIN ANGIOGRAPHY No statistically significant difference was found in documenting vessel calibre and arteriovenous crossing changes [Figure - 4] with either of the methods. Blood flow changes - delayed flow and presence of shunt vessels, capillary bed abnormalities - dilatation, closure, leakage and abnormal formation of vessels - new vessels and microaneurysms could not be seen on direct ophthalmoscopy whereas they were present in 13 patients on fluorescein angiography and this difference was highly significant (p 0.01). Papilledema [Figure - 5] and optic atrophy were seen in 8 and 2 patients respectively both on direct ophthalmoscopy and fluorescein angiography (p 0.05). Soft exudates [Figure - 6][Figure - 7] were visualized equally well with both methods. Hard exudates and macular star could not be visualized on fluorescein angiography and this difference was statistically significant (p 0.05). Presence of haemorrhages was documented equally well with both the methods. Choroidal abnormalities [Figure - 8][Figure - 9] were better seen on fluorescein angiography. Acute Elschnig spots (choroidal infarcts) were seen in 3 patients on fluorescein angiography whereas direct ophthalmoscopy could not visualize them and statistically this difference was highly significant (p 0.01). However, chronic Elschnig spots could be seen on direct ophthalmoscopy in 2 out of the 3 patients having them.
OPHTHALMOSCOPIC AND FLUORESCEIN ANGIOGRAPHY SIGNS IN CONTROLS
3 cases had mild arteriolar narrowing and early arterio venous crossing changes and all of these patients were more than 50 years of age. Branch vein occlusion and capillary bed abnormalities were seen in one patient.
| Discussion|| |
SEVERITY OF HYPERTENSION AND ITS CORRELATION WITH FUNDUS SIGNS
From this study, we conclude that there is a highly significant correlation between the severity of hypertension and the degree of arteriolar narrowing. Focal narrowing is specifically seen in hypertensives, mostly in patients having moderate and severe degree of hypertension. The presence of both generalized and focal narrowing indicates a still higher degree of blood pressure . Advanced arteriovenous crossing changes were more common in hypertensives than in normal subjects but statistically this observation was not found to be significant. A highly significant correlation was found between the severity of blood pressure and presence of exudates, haemorrhages and papilloedema .
CARDIOVASCULAR SIGNS IN HYPERTENSION AND ITS CORRELATION WITH FUNDUS SIGNS Incidence of cardiomegaly and LVH is related directly to the severity of arteriovenous crossing changes  We observed a statistically significant association between marked arteriolar narrowing and various exudative phenomenon like haemorrhages, soft xudates and papilloedema and the presence of LVH and cardiomegaly. The fact that 68.7% of the patients with cardiomegaly and 77% of the patients with LVH in the above study were less than 35 years of age and that more than 70% of these patients had duration of hypertension less than one year, leads us to believe that LVH and cardiomegaly are related to the severity of hypertension rather than to the duration of hypertension or the age of the patient which is contrary to the common belief. Why this difference in hypertension of shorter and longer duration? We attribute this to the fact that longer duration of hypertension indicates either a benign disease or a good control of pressure and in these patients, we do not expect end organ damage.
RENAL FUNCTIONS IN HYPERTENSION AND THEIR CORRELATION WITH FUNDUS SIGNS. We did not find any statistically significant association between arteriolar narrowing, arteriovenous crossing changes, various exudative phenomenon and serum creatinine levels in the hypertensive group as a whole and also in the subset of patients with renal hypertension. Presence of proteinuria showed a significant association with marked narrowing and presence of papilledema in the subset of patients with renal hypertension alone.
CNS MANIFESTATIONS (CVA/HYPERTENSIVE ENCEPHALOPATHY/SEIZURES) IN HYPERTENSION AND THEIR CORRELATION WITH FUNDUS SIGNS In the present study cerebrovascular accident (CVA) was present in 5% of the cases and 18.9% of the cases had CNS manifestations and out of these 85.7% of the patients had severe hypertension. Apart from marked narrowing, no significant association was found between any of the fundus signs and presence of CNS manifestations.
COMPARISON BETWEEN DIRECT OPHTHALMOSCOPIC AND FLUORESCEIN ANGIOGRAPHIC SIGNS
In the present study, we did not observe any statistically significant difference in the measurement of the calibre of retinal vessels with either of the methods. Capillary bed changes viz dilation, closure and leakage were appreciated only on fluorescein angiography and they were seen particularly in the vicinity of soft exudates. Hence, fluorescein angiography is more effective in detecting soft exudates caused by increase in permeability and damage of arteriole walls.  Hard exudates could not be visualized on fluorescein angiography in any of the patients.  Haemorrhages were indicated by presence of blocked fluorescence with equal efficacy on fluorescein angiography and the diagnosis of papilloedema.was confirmed by fluorescein angiography in one disputed case.
Elschnig spots are the result of ischemic infarcts in the choroid arising from acute occlusion of choroidal capillaries or small arterioles.  We saw Elschnig spots in 6 patients by fluorescein angiography while they were visible in only 2 patients on direct ophthalmoscopy. Acute Elchnig spots could not be seen on direct ophthalmoscopy. In one of our patients with hypoplastic kidney who had florid hypertensive retinopathy prior to nephrectomly only healed Elschnig spots were seen six months
later 4 .
Blood pressure control did not significantly alter the calibre of arterioles or arteriovenous changes but there was total resolution of various exudative phenomenon in almost all patients on treatment. Presence of chronic Elschnig spots tells us that the patient had accelerated hypertension in the past. In assessing the response to treatment, fluorescein angiography can reveal subtle changes in the capillary bed.
| References|| |
Keith, N.M., Wagner, H.P. and Barker, N.W. : Some different types of essential hypertension - their course and prognosis Am.J.Med. Soc., 1939.197:332-43
Novotony, H.R. and Alvis, D.L.: A method of photographing fluorescence in circulating blood in human retina Circulation, 1961,24:82-86
Ashton, N. : The eye in malignant hypertension TransacAm Acad Ophthalmol Otolaryngol, 1972.76:17-40
Dollery, C.T. and Hodge, J.V.: Hypertensive retinopathy study with fluorescein Transac Ophthalmol Soc UK, 1964,83:115-126
Gass, J.D.M. : A fluorescein angiographic study of macular dysfunction secondary to retinal vascular disease III hypertensive retinopathy Arch Ophthalmol, 1968.80:569-82
WHO Tech Rep: Quoted from The 1980 report of Joint National Committee on detection evaluation and treatment of high blood pressure (1980) Arch In Med, 1978,140:1280-1285
Srav Dsudd, K.; Wedel, H.; Aurell, E. and Tiblin, G. Hypertensive eye ground changes, prevalence, relation to blood pressure and prognostic importance. the study of new born in 1913 Acta Med Scand, 1978.204:15967
Jain, I.S.; Nagpal, K.C. and Wahi, P.L. : Correlation of fundus signs with systemic signs in hypertension J. Indian Medical Association, 1973.61:7,308
Breslin, D.J.; Gifford, R.W.; Fairbairn, J.F. and Kearns, T.P. : Essential hypertension - a twenty year follow up study Circulation, 1966.33:87-89
Sokolov, A. and Lyon, T.P. : Am Heart Jr, 1949,33:161
Aggarwal. L.P.; Patnaik, B.N. Batta, R.K. and Gupta, A.K. : A correlated study with evolution of an integrated classification of hypertensive retinopathy Orient Arch of Ophthalmology. 1965,3:238
Shelburne, S.A. : Hypertensive retinal disease Grune and Stratton, New York. 1965
Mizobe. A.; Shunsuke, M. and Noboru, M.: Flourescein studies in hypertensive retinopathy Jap Circ JI, 1967,31:789-793
Klein, B.A. : Ischemic infarcts of the choroid (Elschnig spots), a cause of retinal separation of hypertensive disease with renal insufficiency, a clinical and histopathological study. Am JI Ophthal. 1968, 66 : 1069-74.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9]
[Table - 1], [Table - 2]