Hypertension and The Eyes Len V Koh OD Associate Professor

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Hilary Young
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1 Prevalence of hypertension Hypertension and The Eyes Len V Koh OD Associate Professor Most common reason for use of prescription drugs ~ 30% of adults in US ~ 60 million Likely to grow 2014 PUCO PUCO 2 Definition Classification SBP DBP Normal <120 And <80 Prehypertension Or Stage Or Stage 2 >160 Or >100 Severe >180 >120 White coat hypertension & ambulatory monitoring ~20 25% of patients More common in the elderly Repeat the measurement Ambulatory blood pressure monitoring (ABPM) Every min Confirm or exclude white coat hypertension >50 yo: systolic BP > 140 mmhg predicts mortality <50 yo: diastolic pressure is a better predictor of mortality 2014 PUCO PUCO 4 Target Blood Pressure <140/90 <130/80 with diabetes or renal disease 35 40% reduction in stroke 20 25% reduction in MI >50% reduction in heart failure The distribution of drugs being used by the patients 2014 PUCO PUCO 6 1

2 Lifestyle modification Only half under control Poor access to health care Lack of adherence Side effects The data are for adults age 18 to 74 years of age with a systolic pressure 140 mmhg and/or a diastolic pressure 90 mmhg. * Control is defined as a systolic pressure below 140 mmhg and a diastolic pressure below 90 mmhg PUCO PUCO 8 Hypertensive complications Coronary heart disease Stroke Chronic kidney disease Congestive heart failure Ocular abnormalities Retinopathy Choroidopathy Optic neuropathy 2014 PUCO 9 Pathophysiology of hypertensive retinopathy Initial response: vasospasm & an increase in vasomotor tone Generalized retinal arteriolar narrowing Chronic response: Intimal thickening, mediawall hyperplasia, hyaline degeneration Diffuse and focal areas of arteriolar narrowing, silver or copper wiring Arteriovenous nipping or nicking Late response: blood retinal barrier breaks down Hemmorrhages, exudates, cotton wool spots, disc swelling 2014 PUCO 10 AV Nicking Arching of the retinal vein 2014 PUCO PUCO 12 2

3 Classification of Hypertensive Retinopathy Associated Ocular Conditions Retinal macroaneurysms ~ 80% Ocular ischemic syndrome ~70% Retinal vascular occlusion ~ 50% Ischemic optic neuropathy ~ 50% Diabetic retinopathy Every 10 mmhg increase in SBP increases risk of retinopathy by 10% and PDR by 15% Prevalence: 2 14% 2014 PUCO PUCO 14 Examples of Mild Hypertensive Retinopathy Examples of Moderate Hypertensive Retinopathy PUCO PUCO 16 Example of Malignant Hypertensive Retinopathy. 3 year incident stroke 2014 PUCO PUCO 18 3

4 HR severity and management Retinal Vein Occlusion Retinopathy BP RTC Mild / year Moderate / months / months, PCP 2 4 weeks Hypertensive crisis >180/>120 Mild Urgent BP control 2 7 days Moderate Severe Urgent BP control 1 2 days Emergent ER BP control <2 h RTC: 1 3 mo RTC: 1 mo RTC: 1 mo A common, sight threatening retinalvascular disorder Hemorrhages, CWS, Edema CRVO: % Ischemic CRVO Non ischemic CRVO BRVO: % Hypertension: 5X more likely to have BRVO 2014 PUCO PUCO 20 Retinal Emboli Asymptomatic retinal emboli are fairly common 1.3% and 1.4% 10 year incidence 2.9% Transient Hypertension: 2X higher risk, 6X higher risk with smoking RAO and thromboembolic stroke Retinal Artery Occlusion RAO occurs commonly in patients with HTN Hematological abnormalities and stroke Absolute risk of death 8% per year Visible emboli, higher mortality 2014 PUCO PUCO 22 Retinal Macroaneurysm Almost always seen in HTN Dilatation, hyperpermeability, rupture 20% bilateral Visual loss secondary to hemorrhages or exudation Ischaemic Optic Neuropathy Anterior accounts for 90% of cases Sudden visual loss & optic disc edema Arteritic form = GCA Nonarteritic AION strongly associated with HTN 10.3 per 100,000 people 50% with HTN 25% with DM 2014 PUCO PUCO 24 4

5 Diabetic Retinopathy Less tight control (<180/105) Tight control (<150/85) 37% reduction in microvascular disease, 34% reduction in retinopathy progression 47% reduction in VA deterioration Each 10 mmhg reduction of SBP, the risk of retinopathy might fall by 10%. Age related macular degeneration Beaver Dam Eye Study raised SBP increases the 10 year risk of AMD Blue Mountain Study focal arteriolar narrowing was associated with AMD signs 2014 PUCO PUCO 26 Glaucoma Impair blood flow to the anterior optic nerve Interfere with autoregulation of the posterior ciliary circulation Antihypertensive treatment could induce hypotensive episodes Hypertensive Retinopathy Associated with Preeclampsia 2014 PUCO PUCO 28 Summary on Hypertensive Retinopathy Most patients have primary HTN Race, genetics, diet, exercise Hypertensive retinopathy Other ocular complications Eye care providers play an important role References Wong TY, Mitchell P. The eye in hypertension. Lancet 2007; 369:425. Gudmundsdottir H, Taarnhøj NC, Strand AH, et al. Blood pressure development and hypertensive retinopathy: 20 year follow up of middle aged normotensive and hypertensive men. J Hum Hypertens 2010; 24:505. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004; 351:2310. Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: their course and prognosis. Am J Med Sci 1974; 268:336. Sharrett AR, Hubbard LD, Cooper LS, et al. Retinal arteriolar diameters and elevated blood pressure: the Atherosclerosis Risk in Communities Study. Am J Epidemiol 1999; 150:263. Wong TY, Klein R, Sharrett AR, et al. Retinal arteriolar diameter and risk for hypertension. Ann Intern Med 2004; 140:248. Wong TY, Klein R, Couper DJ, et al. Retinal microvascular abnormalities and incident stroke: the Atherosclerosis Risk in Communities Study. Lancet 2001; 358:1134. Ong YT, Wong TY, Klein R, et al. Hypertensive retinopathy and risk of stroke. Hypertension 2013; 62:706. Wong TY, Klein R, Sharrett AR, et al. Retinal arteriolar narrowing and risk of coronary heart disease in men and women. The Atherosclerosis Risk in Communities Study. JAMA 2002; 287: PUCO PUCO 30 5

2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY

2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented National Quality Strategy Domain: Community / Population Health 2016 PQRS OPTIONS F INDIVIDUAL MEASURES: