Hypertension

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There are several systems for grading the fundus changes in hypertension (eg, grade I or grade II). Do not do this: describe what you see. Hypertension produces a number of changes and signs in the fundus:

1. Diffuse and focal or segmental constriction of the retinal arteries—The older the patient, the less significant is the arterial narrowing. The earliest narrowing occurs in the retinal periphery. Tortuousity of the arteries is most evident at the disc edge, and this change is indistinguishable from arteriosclerotic changes unrelated to hypertension.

2. Disc edema—It looks the same as disc edema resulting from any other cause.

3. Arteriovenous "nicking"—This may produce relative venous obstruction and retinal hemorrhages distal to the arteriovenous crossings.

4. Retinal hemorrhages—Widely distributed over the retina (in contrast, a radial arrangement is seen around the disc in papilledema), petechial and larger and often round, as well as flame-shaped. Look distal to the arteriovenous crossings.

5. Exudates (spots, streaks, and clusters of white to gray material in the retina)—These may be arranged radially around the macula in a star configuration.

Remember:

1. Increased intracranial pressure may produce papilledema.

2. Start with a +8 to +10 lens, diminishing the magnification until the disc is in focus. Note the magnification and then diminish the magnification further until the retina is in focus.

3. The more acute the onset of the papilledema, the more hemorrhages are present; these are arranged radially around the disc.

4. Vision is initially normal, with an enlarged blind spot.

5. Papillitis and retrobulbar neuritis may cause nerve head swelling; characteristically, these cause central blindness and eye pain.

6. Elevated blood pressure may cause disc edema:

a. With diffuse and focal arterial changes b. With venous nicking and venous obstruction at the arteriovenous crossings c. With a variety of hemorrhages diffusely seen in the retina often from veins distal to the arteriovenous crossings d. With exudates

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