Correlation between hypertensive retinopathy and fetal outcomes in patients with preeclampsia in a tertiary care hospital: A prospective cohort study

Purpose: To study the effect of increasing grades of hypertensive retinopathy (HTR) on neonatal outcomes among preeclamptic women and assess the various maternal risk factors for HTR. Methods: A prospective cohort study was conducted on 258 preeclamptic women. The systolic and diastolic blood pressure (SBP and DBP), liver, and renal function parameters were collected besides basic demographic details. Dilated fundus examination with the Keith–Wagner–Barker classification was used to grade HTR. Following delivery, neonatal outcomes were evaluated. Results: Of the 258 preeclamptic women recruited, 53.1% had preeclampsia (PE), and 46.9% had severe preeclampsia. With increasing grades of HTR, a significant association with low birth weight (LBW) (p = 0.012) and preterm gestational age (p = 0.002) was noted but not with the Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score (p = 0.062). Also, it did not increase the risk of retinopathy of prematurity (ROP), with most babies, even those born to mothers with high grades of HTR, showing no evidence of ROP (p = 0.025). Among the maternal factors, increasing age (p = 0.016), SBP (p < 0.001), DBP (p < 0.001), serum creatinine (p = 0.035), alanine aminotransferase (p = 0.008), lower hemoglobin (Hb) (p = 0.009), lower platelet (p < 0.001), and severe PE (p < 0.001) have been found to significantly affect the grade of HTR. Conclusion: Higher grades of HTR in the preeclamptic mother are associated with preterm delivery and LBW of the neonates but neither affect the APGAR score nor pose the risk of developing ROP

El fondo de ojo, una ventana a la microvasculatura del paciente hipertenso / The fundus, a window to microvasculature in hypertensive patients

Introducción: La hipertensión arterial constituye una de las enfermedades más frecuentes en la población general. En la actualidad llega a una prevalencia global del 30 al 45 %. La microcirculación retiniana puede considerarse como una representación anatómica de las características fisiológicas y funcionales de la circulación coronaria y cerebral. Objetivos: Profundizar en la relación existente entre los niveles de presión arterial y el daño del órgano diana, específicamente a través del fondo de ojo, así como de las posibles complicaciones oftalmológicas derivadas de la hipertensión arterial, y la comparación de algunas de las clasificaciones existentes sobre los cambios oftalmológicos que esta provoca. Métodos: Se emplearon los métodos de análisis-síntesis y análisis bibliográfico y documental. Los motores de búsqueda utilizados fueron: Google y Google Académico, y las bases de datos Hinari, SciELO Cuba, Pubmed, entre otras. Conclusiones: La retinopatía hipertensiva es una de las complicaciones adversas de la hipertensión arterial aguda o crónica. Por su parte, las oclusiones venosas y la formación de macroaneurismas, constituyen otras de gran envergadura. Mientras más eficaz sea el diagnóstico y seguimiento de los pacientes hipertensos, menos recursos se necesitarán para su tratamiento, y se evitarán así las complicaciones de otros órganos diana como el cerebro y el riñón, lo que provocaría en los pacientes una mayor discapacidad.

Introduction: arterial hypertension is one the most frequent diseases in general population. Nowadays, it reaches a global prevalence of 30 to 45 %. Retinal microcirculation can be considered as an anatomical representation of the physiological and functional characteristics of the coronary and cerebral circulation. Objectives: to delve into the relationship between blood pressure levels and target organ damage, specifically through the fundus, as well as the possible ophthalmological complications derived from arterial hypertension, and the comparison of some of the existing classifications on the ophthalmological changes that it causes. Methods: analysis - synthesis and bibliographic- documentary analyses were the used methods. Google and Google Scholar as well as Hinari, SciELO Cuba, Pubmed and others databases were the search engines. Conclusions: hypertensive retinopathy is one of the adverse complications of acute or chronic arterial hypertension. On the other hand, venous occlusions and the formation of macroaneurysms constitute other serious ones to consider. The more effective the diagnosis and follow-up of hypertensive patients, the fewer resources will be needed for their treatment, thus avoiding complications in other target organs such as the brain and kidney, which would cause greater disability in patients.

Severe bilateral visual loss as the first sign of IgA nephropathy / Perda visual bilateral grave como o primeiro sinal da nefropatia por IgA

ABSTRACT We describe a case of a 33-years-old woman who presents with severe acute bilateral visual loss secondary to massive exudative hypertensive maculopathy as the first sign of immunoglobulin A nephropathy. The patient's ophthalmic examination showed bilateral cotton-wool spots, flame-shaped retinal hemorrhages, diffuse narrow arterioles, optic disk edema, and exudative maculopathy. Systemic workup demonstrated a systolic and diastolic blood pressure of 240 mmHg and 160 mmHg, respectively, proteinuria, and hematuria, suggesting kidney disease as the causative condition. A kidney biopsy confirmed immunoglobulin A nephropathy. She was treated with systemic corticosteroids, antihypertensive drugs, and a single bilateral intravitreal injection of aflibercept. There was a prompt resolution of macular edema and vision improvement. Our case draws attention to the fact that severe bilateral visual loss can be the first sign of severe hypertension. Secondary causes, such as immunoglobulin A nephropathy, should be ruled out.

RESUMO Nosso objetivo é descrever uma paciente de 33 anos de idade, com perda visual bilateral grave por maculopatia hipertensiva exsudativa como o primeiro sinal da nefropatia por imunoglobulina A. A fundoscopia revelou a presença de manchas algodonosas, hemorragias em chama-de-vela, estreitamento arteriolar difuso, edema de disco óptico e maculopatia exsudativa bilateral. A pressão arterial sistólica foi de 240mmHg e a diastólica de 160 mmHg associado a proteinúria e hematúria, sugerindo a presença de doença renal. A biópsia renal confirmou a nefropatia por imunoglobulina A. A paciente foi tratada como corticoide sistêmico, drogas anti-hipertensivas e uma única dose intravítrea de Aflibercept em ambos os olhos. Houve rápida melhora do edema macular e da acuidade visual. Nosso caso chama a atenção para o fato de que a perda visual bilateral grave pode ser a primeira apresentação de uma doença hipertensiva sistêmica. Causas secundárias como a nefropatia por imunoglobulina A devem ser afastadas.

Early changes of retinal and choroidal microvascular structure in hypertensive patients / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To explore the feasibility of swept source optical coherence tomography angiography(SS-OCTA)in evaluating early retinal and choroidal microcirculation changes in patients with hypertension.METHODS:Prospective clinical study. A total of 27 patients with grade 2 or 3 essential hypertension(hypertension group)diagnosed in the Department of Cardiology of Xi'an First Hospital from July to November 2022 were included in the study. There were 14 males and 13 females. The mean age was(57.11±3.36)years. During the same period, 27 age- and sex-matched normal people without a history of hypertension were selected as the control group, including 12 males and 15 females. The average age was(55.74±2.95)years old. All patients underwent BCVA(LogMAR), intraocular pressure, axial length, slit lamp examination, fundus color photography and SS-OCTA examination. SS-OCTA was used to scan the macular area of the right eye in the range of 6×6 mm. The retina and choroid were divided into three concentric circles with diameters of 0-1 mm, 1-3 mm and 3-6 mm around the fovea according to ETDRS. Macular vessel density(VD), perfusion area(PA), retinal thickness(CMT), choroidal thickness(CT), choroidal vessel volume(CVV)and choroidal vasculr index(CVI)of the superficial capillary plexus(SCP)and the deep capillary plexus(DCP)in the macular area of 0-1 mm, 1-3 mm and 3-6 mm were analyzed and recorded. The changes in VD, PA, CMT, CT, CVV and CVI were compared between the two groups. Independent sample t-test was used to compare VD, PA, CMT and CVI between the two groups; CT, CVV and LogMAR visual acuity were analyzed by Wilcoxon signed rank test of independent samples.RESULTS:Compared with the control group, the hypertensive group had significantly lower VD in the macular area 0-3 mm(0-1 mm, t=-3.144; 1-3 mm, t=-3.611, P&#x003C;0.05). VD in the area of 3-6 mm showed a tendency to increase compared with the control group(t=1.715, P&#x003E;0.05). The CMT in the 0-1mm area of the macular area in the hypertension group was lower than that in the control group(t=-2.624, P&#x003C;0.05). There was no significant difference in CT, CVV and CVI between the two groups(P&#x003E;0.05).CONCLUSION:The VD of DCP in the 0-3 mm area and the CMT in the 0-1 mm area are decreased in hypertensive patients. There were no significant differences in CT, CVV and CVI between the two groups. VD and CMT in macular DCP may be used as indicators to evaluate the early changes of retinal and choroidal microcirculation in hypertensive patients.

Impacto de la retinopatía hipertensiva asociada a cardiopatías coronarias

Introducción: La asociación entre la retinopatía hipertensiva y cardiopatías coronarias es un tema de una larga controversia. La retinopatía hipertensiva ha sido definida como un predictor de mortalidad y morbilidad en pacientes hipertensos desde hace mucho tiempo. Además, estudios recientes han demostrado que la microvasculatura retiniana refleja la patología en los pequeños vasos sistémicos, incluida la microcirculación coronaria. Objetivos: El objetivo fue realizar una revisión sistemática y un análisis cualitativo y cuantitativo mediante un metanálisis para determinar la asociación entre la retinopatía hipertensiva y cardiopatías coronarias. Métodos: Se realizó la búsqueda sistemática de estudios relacionados con el tema. La fuente de búsqueda fue PubMed y Google Scholar. La revisión sistemática y meta-análisis se desarrollaron con las pautas Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Resultados: Se demostró que existe una asociación entre la retinopatía hipertensiva y la enfermedad de la arteria coronaria. (P=0,01; RR 1,29; IC 95 %: 1,06 a 1,56), se evaluó la hipertrofia ventricular izquierda como desenlace, se encontró un efecto estadísticamente significativo que asocia a la retinopatía hipertensiva con la hipertrofia ventricular izquierda (p=0,03; RR: 1,71; IC 95 %: 1,31 a 2,24). Conclusiones: Se encontró asociación entre retinopatía hipertensiva y las cardiopatías coronarias más frecuentes (Enfermedad coronaria e HVI).

Introduction: The association between hypertensive retinopathy and coronary heart disease is a subject of long-standing controversy. Hypertensive retinopathy has long been defined as a predictor of mortality and morbidity in hypertensive patients. In addition, recent studies have shown that the retinal microvasculature reflects pathology in small systemic vessels, including the coronary microcirculation. Objectives: The aim was to perform a systematic review and a qualitative and quantitative analysis by meta-analysis to determine the association between hypertensive retinopathy and coronary heart disease. Methods: A systematic search for studies related to the topic was performed. The search source was PubMed and Google Scholar. The systematic review and meta-analysis were developed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Results: An association between hypertensive retinopathy and coronary artery disease was demonstrated (P=0.01; RR 1.29; 95 % CI: 1.06 to 1.56), left ventricular hypertrophy was evaluated as an outcome, a statistically significant effect was found associating hypertensive retinopathy with left ventricular hypertrophy (P=0.03; RR: 1.71; 95 % CI: 1.31 to 2.24). Conclusions: An association was found between hypertensive retinopathy and the most frequent coronary heart diseases (coronary artery disease and LVH).

Hallazgos de la ecografía Doppler arterial oftálmica en pacientes con hipertensión arterial primaria / Ophthalmic Arterial Doppler Ultrasound Findings in Patients with Primary Arterial Hypertension

Objetivo: Determinar los hallazgos por ecografía Doppler arterial oftálmica en pacientes con hipertensión arterial primaria. Métodos: Se efectuó un estudio observacional descriptivo y transversal con 202 órbitas de 101 pacientes hipertensos, a los que se les realizó fondo de ojo para diagnóstico y gradación de la retinopatía hipertensiva. Por interrogatorio y examen físico se identificaron como factores de riesgo aterosclerótico el consumo excesivo de alcohol y la obesidad. Además, se les hizo ultrasonido orbitario y Doppler carotídeo, y solo en caso de resultar normales, se procedió a evaluar mediante ecografía Doppler las arterias oftálmicas. Resultados: Predominaron los hipertensos entre 40 y 60 años de edad, el sexo masculino, el color mestizo de piel, los casos sin retinopatía hipertensiva, y el grupo entre 10 y 20 años de diagnosticada la hipertensión. Se demostró un incremento de la velocidad del flujo y de la resistencia vascular a nivel de las arterias oftálmicas. En tanto, se evidenció asociación significativa de estos parámetros hemodinámicos con el envejecimiento y el tiempo de diagnóstico de la hipertensión. Sin embargo, no se comprobó asociación significativa con el sexo, el color de la piel, y la presencia o ausencia de obesidad, consumo excesivo de alcohol, y retinopatía hipertensiva independientemente de su gravedad. Conclusiones: La evaluación de las arterias oftálmicas mediante ecografía Doppler permite hacer un estudio y seguimiento más integral de los pacientes con hipertensión arterial primaria(AU)

Objective: To determine ophthalmic arterial Doppler ultrasound findings in patients with primary arterial hypertension. Methods: A descriptive and cross-sectional observational study was carried out with 202 orbits of 101 hypertensive patients, who underwent fundus examination for diagnosis and grading of hypertensive retinopathy. By interrogation and physical examination, excessive alcohol consumption and obesity were identified as atherosclerotic risk factors. In addition, orbital ultrasound and carotid Doppler were performed, and only if they were normal, the ophthalmic arteries were evaluated using Doppler ultrasound. Results: Hypertensive patients between 40 and 60 years of age, male, mixed skin color, cases without hypertensive retinopathy, and the group between 10 and 20 years after hypertension diagnosis predominated. An increase in flow velocity and vascular resistance at the level of the ophthalmic arteries was demonstrated. Meanwhile, a significant association of these hemodynamic parameters with aging and time of diagnosis of hypertension was evidenced. However, no significant association was found with gender, skin color, and the presence or absence of obesity, excessive alcohol consumption, and hypertensive retinopathy regardless of its severity. Conclusions: Evaluation of the ophthalmic arteries using Doppler ultrasound allows a more comprehensive study and follow-up of patients with primary arterial hypertension(AU)

Complicaciones vasculares en pacientes hipertensos jóvenes de un hospital de Paraguay

RESUMEN Introducción: la hipertensión arterial es una enfermedad que se caracteriza por la elevación sostenida de la presión arterial. Su aparición a temprana edad se ha duplicado en los últimos años, por lo que se espera un incremento de las complicaciones vasculares relacionadas a ella, como la manifestación de accidente cerebrovascular isquémico o hemorrágico, infarto agudo de miocardio, nefropatía hipertensiva, preeclampsia, eclampsia. Los factores de riesgos asociados de gran influencia como el antecedente patológico familiar entre otros se encuentran relacionados a su aparición. Objetivo: determinar las características clínicas de pacientes hipertensos menores de 50 años en el Hospital Nacional, Itauguá, Paraguay, en el periodo 2020-2021. Metodología: estudio observacional, descriptivo, retrospectivo de corte transversal, analítico que incluyo 150 pacientes con hipertensión arterial, de ambos sexos, menores de 50 años. Resultados: la edad media de la muestra fue 39 años, con rango entre 15-50 años, la mayoría provenía del área urbana, con nivel educativo secundario. Hubo predominio del sexo femenino (52%), sin embargo, las complicaciones vasculares fueron más frecuentes en el sexo masculino. Las complicaciones vasculares se detectaron en 89%, predominando el accidente cerebrovascular (26%), la retinopatía hipertensiva (24%) y la nefropatía de origen hipertensivo (22,6%). La mayoría de los pacientes presentaba factores de riesgo cardiovascular asociados, los principales fueron el sedentarismo y la diabetes mellitus tipo 2, así como el antecedente patológico familiar de hipertensión arterial. Conclusión: las principales complicaciones fueron el accidente cerebro vascular (26%), la retinopatía hipertensiva (24%) y la nefropatía de origen hipertensivo (22,6%). Se recomienda la detección precoz y el tratamiento oportuno de los hipertensos jóvenes.

ABSTRACT Introduction: Hypertension is a disease characterized by sustained elevation of blood pressure. Its appearance at an early age has doubled in recent years, therefore an increase in vascular complications related to it is expected, such as the manifestation of ischemic or hemorrhagic stroke, acute myocardial infarction, hypertensive nephropathy, preeclampsia, eclampsia. Associated risk factors of great influence, such as family pathological history, among others, are related to its appearance. Objective: To determine the clinical characteristics of hypertensive patients under 50 years of age at the Hospital Nacional of Itauguá, Paraguay, in the period 2020-2021. Methodology: Observational, descriptive, retrospective, cross-sectional, analytical study that included 150 male and female patients with arterial hypertension under 50 years of age. Results: The average age of the sample was 39 years, with a range between 15-50 years, the majority came from the urban area, and had secondary education level. There was a predominance of women (52%), however, vascular complications were more frequent in men. Vascular complications were detected in 89%, predominantly stroke (26%), hypertensive retinopathy (24%) and hypertensive nephropathy (22.6%). Most of the patients had associated cardiovascular risk factors, the main ones being sedentary lifestyle and type 2 diabetes mellitus, as well as a family pathological history of high blood pressure. Conclusion: The main complications were cerebrovascular accident (26%), hypertensive retinopathy (24%) and hypertensive nephropathy (22.6%). Early detection and timely treatment of young hypertensive patients is recommended.

Retinopatia hipertensiva maligna secundária a lúpus eritematoso sistêmico em adolescente / Malignant hypertensive retinopathy secondary to systemic lupus erythematous in adolescent

RESUMO O lúpus eritematoso sistêmico é uma doença que pode apresentar comprometimento oftalmológico geralmente benigno, sendo as alterações mais encontradas a síndrome do olho seco e a catarata. Nos pacientes com a doença estável, o dano oftalmológico parece estar relacionado ao tratamento sistêmico a longo prazo, o que enfatiza a importância do exame oftalmológico completo de rotina. Porém, quando a doença está em franca atividade e, em especial, quando há o envolvimento renal, deve-se iniciar o tratamento precoce com corticoterapia sistêmica e com medidas de suporte, para se evitarem repercussões mais complexas, como as crises hipertensivas que podem levar ao óbito.

ABSTRACT Systemic lupus erythematosus may present ophthalmological involvement, usually benign, and the most common changes are dry eye syndrome and cataract. In patients with stable disease, ophthalmologic damage appears to be related to long-term systemic treatment, emphasizing the importance of routine complete ophthalmologic examination. However, in full-blown disease, especially when there is renal involvement, early treatment should start with systemic steroid therapy and supportive measures, to avoid major repercussions, such as hypertensive crises that may lead to death.

Retinal changes among pre-eclamptic patients in University of Benin Teaching Hospital, Benin, Nigeria

Background: Preeclampsia is one of the hypertensive disorders in pregnancy that contributes significantly to maternal and fetal morbidity and mortality, with the impact felt more in developing countries. It is characterized by endothelial dysfunction and vasospasm of vessels which can be observed by an ocular fundal examination. The aim of this study was to determine the ocular fundus findings of women with preeclampsia. Methods: This was a cross-sectional study, carried out at the University of Benin Teaching Hospital involving a total of 220 pregnant women. The women were divided into two groups of 110 pregnant women (A&B).Their Age and Gestational age was cross-matched and retinopathy graded according to Keith and Wagner classification. Group A was made up of Preeclamptic women and Group B was made up of healthy pregnant women. Visual acuity was measured using Snellens' chart, and the fundus was examined with direct ophthalmoscope. Results: This showed that the retinal changes observed in the preeclamptic women were associated with their age (P = 0.009), gestational age (P = 0.044), blood pressure (P = 0.001), Proteinuria (P = 0.001), Severity of the disease (P = 0.001), visual acuity (P = 0.035) as well as with the visual symptoms (P = 0.001) but not statistically significant with the gravida (P = 0.799). Conclusion: Our study highlights the importance of timely ophthalmoscopy which helps to assess severity of disease (pre-eclampsia) which affects the decision of induction of delivery to predict and prevent possible complications which in turn immensely helps in judicious management of disease. Also, the study revealed that preeclamptic women who are multigravida are more likely to have retinopathy than primigravid

Analytical Study of Retinal Vessel Changes as a Predictor of Coronary Artery Disease in Elderly Hypertensives Presenting with Angina.

Coronary artery disease is an important cause of cardiovascular morbidity and mortality all over the world. Hypertension has been identified as an important risk factor for the development of CAD. Retinal vessel changes can occur in patients with uncontrolled or poorly controlled hypertension and are a predictor of the effect of hypertensive damage in the body. Retina is a place where end artery circulation can be directly visualized and quantifying retinal vessel changes in hypertensive patients presenting with angina can help in determining the risk and identifying those patients who need coronary angiogram especially in a primary care set up as it is an expensive investigation. We wanted to analyse retinal vessel changes in elderly hypertensives presenting with angina and correlate the same with the risk of developing coronary artery disease.METHODS50 elderly hypertensives who presented with acute angina were included in the study and were subjected to a coronary angiogram. They were divided into case and control groups. Those with the disease on angio are taken as cases and those without are considered as controls. The effect of age, sex, BMI, smoking, presence of retinopathy, LVH on ECG, grade of retinopathy were all analysed and correlated with the risk of developing CAD.RESULTSAge, Sex, BMI, smoking, LVH had no relation with development of CAD in our study. Presence of retinopathy had a significant correlation with development of CAD (p = 0.031, p<0.05) with OR of 5.81. Commonest grade of retinopathy in our study was Grade 2 and this also showed a significant correlation with the risk of developing CAD.CONCLUSIONSRetinal vessel changes are a significant predictor of risk of developing CAD in elderly hypertensives presenting with angina. The risk of developing CAD was six fold more in those with retinopathy changes and this can help as a screening tool to determine those who need angiography in a primary setting.

The image characteristics of multispectral scanning laser imaging and optical coherence tomography in patients with pregnancy induced hypertension syndrome / 中华眼底病杂志

Objective To observe the image characteristics ofmultispectral scanning laser imaging (MSLI) and OCT in patients with pregnancy induced hypertension syndrome (PIHS).Methods A total of 112 patients (224 eyes) of PIHS patients diagnosed in Obstetrics Department of Tianjin First Central Hospital from May 2016 to May 2017 were included in this study.The average age of the patients was 27.00±2.14 years.The average course of the disease was 15.00 ±8.27 days.There were 174 eyes in 87 patients of blurred vision,dazzling and visual fatigue consciously.All patients performed BCVA,direct ophthalmoscope,B ultrasound,confocal scanning laser Ophthalmoscope (cSLO) and spectral-domain OCT (SD-OCT).SD-OCT was performed with Spectralis HRA+OCT from Heidelberg Company in Germany to acquire tomographic images.Using Herdelberg's colorful program (MultiColor) based on cSLO and operating in accordance with standard methods,one scan simultaneously obtained blue light reflection based on 488 nm,green light reflection based on 515 nm,and infrared reflection based on 820 nm,synthesis to MSLI.Fundus abnormalities were classified into arterial spasm (stage Ⅰ),arteriosclerosis (stage Ⅱ),and retinopathy (stage Ⅲ).OCT examination was divided into normal and abnormal cases according to the abnormality of retinal morphology and thickness.Results Of the 224 eyes,68 eyes (30.36％) showed normal fundus examination and 156 eyes (69.64％) showed abnormal fundus performance.Among them,28 eyes were stage Ⅰ (17.95％);40 eyes were stage Ⅱ (25.64％);88 eyes were stage Ⅲ (56.41％).Thirty-six eyes (16.07％) showed normal fundus and 188 eyes (83.93％) showed abnormal performance with OCT.Of the 188 eyes with abnormal fundus performance,86 eyes (45.74％) had retinal neuroepithelial serous detachment;56 eyes (29.79％) had RPE detachment;optic disc edema,bulge,and local reflexes in the retinal nerve fiber layer were enhanced and/or the thickness increased in 46 eyes (24.47％).In MSLI,48 eyes (21.43％) showed normal fundus;176 eyes (78.57％) showed abnormal performance.Retinal edema was showed in green on MSLI,serous retinal neuroepithelial layer detachment,RPE layer detachment,retinal nerve fiber layer thickening,accompanied by changes in local retinal structure.The higher the degree of bulge,the darker the color.Consistent with the range of retinal edema revealed by SD-OCT.Conclusions MSLI and SD-OCT images show highly consistent lesions in PIHS patients.MSLI can more clearly show superficial and deep retinal lesions.

Endothelial lesion and complement activation in patients with Scleroderma Renal Crisis / Lesão endotelial e ativação do complemento em pacientes com crise renal esclerodérmica

Abstract In kidney biopsies reviews, scleroderma renal crisis (SRC) is characterized by vascular endothelial injuries, C4d deposits on peritubular vessels, and acute and chronic injuries coexisting on the same biopsy. The clinical signs of thrombotic microangiopathy (TMA) are described in systemic sclerosis (SSc), nevertheless, it has not been related to acute injuries described on kidney biopsies. We report a case of SRC in a patient with scleroderma-dermatomyositis overlap syndrome, which also showed clinical and histopathological data of TMA. On fundus examination, a severe acute hypertensive retinopathy was found. The kidney biopsy showed severe endothelial damage with widening of mucoid cells at the level of the intima, focal concentric proliferation on most small arterioles, and C3, C4d, and IgM deposits along the capillary walls. The genetic study of complement only showed the presence of membrane cofactor protein (MCP) risk haplotypes, without other genetic complement disorders. We understand that in a patient with TMA and SSc, the kidney damage would be fundamentally endothelial and of an acute type; moreover, we would observe clear evidence of complement activation. Once further studies correlate clinical-analytical data with anatomopathological studies, it is likely that we will be forced to redefine the SRC concept, focusing on the relationship between acute endothelial damage and complement activation.

Resumo Nas revisões de biópsias renais, a crise renal esclerodérmica (CRE) é caracterizada por lesões endoteliais vasculares, depósitos de C4d em vasos peritubulares e lesões agudas e crônicas que coexistem na mesma biópsia. Os sinais clínicos de microangiopatia trombótica (MAT) são descritos na esclerose sistêmica (ES); no entanto, não foram relacionados às lesões agudas descritas nas biópsias renais. Relatamos um caso de CRE em um paciente com síndrome de superposição de esclerodermia-dermatomiosite, que também apresentou dados clínicos e histopatológicos de MAT. No exame de fundo do olho, foi encontrada uma retinopatia hipertensiva aguda grave. A biópsia renal mostrou lesão endotelial grave com alargamento das células mucoides ao nível da íntima, proliferação concêntrica focal na maioria das pequenas arteríolas e depósitos de C3, C4d e IgM ao longo das paredes dos capilares. O estudo genético do complemento mostrou apenas a presença de haplótipos de risco da proteína cofator de membrana (PCM), sem outros distúrbios genéticos do complemento. Entendemos que em um paciente com MAT e ES, o dano renal seria fundamentalmente endotelial e do tipo agudo; além disso, observaríamos evidências claras de ativação do complemento. Uma vez que novos estudos correlacionam dados clínico-analíticos com estudos anatomopatológicos, é provável que sejamos forçados a redefinir o conceito de CRE, enfocando a relação entre dano endotelial agudo e ativação do complemento.

Posterior reversible encephalopathy syndrome presenting with atypical findings: case study

PRES (posterior reversible encephalopathy syndrome) is a syndrome characterized by headache, confusion, seizures and altered mental status. A 26 years old woman came to emergency department with a history of hypertension, blurred vision and seizures. She was diagnosed as a G3P2L1 at 29 weeks + 1 day with IUGR with preeclampsia associated with deranged kidney functions later complicated by development of PRES. Patient underwent emergency LSCS and was kept on mechanical ventilator as condition worsened during immediate post-operative period. Dialysis was also done to regulate urea and creatinine levels. Patient was treated with anti-hypertensive, anti-epileptics, antibiotics, intravenous fluids and continuous monitoring of blood pressure. Patient’s condition improved gradually, and her discharge was planned. PRES is a condition, if managed in initial phase can lead to early recovery and reduce mortality.

Optical coherence tomography angiography findings in malignant hypertensive retinopathy / Achados da angiografia por tomografia de coerência óptica na retinopatia hipertensiva maligna

ABSTRACT A 33-year-old male presented to our clinic with low vision in both eyes that started during the previous week. Visual acuity was 20/63 in the right eye and 20/50 in the left eye. Fundus examination revealed signs of hypertensive retinopathy; thus, a multidisciplinary approach was adopted for the diagnosis and treatment of this patient. We consulted the nephrology and cardiology departments on this case. Upon diagnosing malignant hypertension and renal failure, the patient was put on hemodialysis. His visual acuity was 20/20 at 6 months, whereas foveal assessment on optical coherence tomography angiography revealed neither marked superficial and deep capillary density loss and foveal avascular zone enlargement nor a decrease in disc flow and radial peripapillary capillary density. Early diagnosis and treatment of malignant hypertension are critical in preventing progression of end-organ damage including the eyes. Optical coherence tomography angiography may be useful in cases when fundus fluorescein angiography is relatively contraindicated (e.g., renal failure).

RESUMO Um homem de 33 anos apresentou-se à nossa clínica com baixa visão em ambos os olhos que começou uma semana antes. A acuidade visual foi de 20/63 no olho direito e 20/50 no olho esquerdo. O exame de fundo de olho revelou sinais de retinopatia hipertensiva; então, adotou-se uma abordagem multidisciplinar para o diagnóstico e tratamento desse paciente. Consultamos os departamentos de nefrologia e cardiologia neste caso. Ao diagnosticar hipertensão maligna e insuficiência renal, o paciente foi colocado em hemodiálise. Sua acuidade visual era 20/20 aos 6 meses, enquanto a avaliação foveal com angiotomografia de coerência óptica não revelou perda de densidade capilar superficial e profunda acentuada e aumento da zona avascular foveal nem uma diminuição no fluxo de disco e na densidade capilar peripapilar radial. O diagnóstico precoce e o tratamento da hipertensão maligna são fundamentais na preveção da progressão de danos nos órgãos-alvo, incluindo os olhos. A Angiografia por tomografia de coerência óptica pode ser útil nos casos em que a angiografia com fluoresceína do fundo de olho é relativamente contraindicada (por exemplo, insuficiência renal).

Dramatic response to intravitreal Bevacizumab in hypertensive retinopathy

Hypertensive retinopathy is seen frequently in patients with systemic hypertension and is usually asymptomatic. An acute rise in blood pressure may lead to exudative changes in the form of macular edema, hemorrhages, and serous macular detachment that can lead to visual decline. The authors report prompt resolution of exudative changes in a case of hypertensive retinopathy following intravitreal bevacizumab.

Bilateral Obstructive Uropathy Caused by Congenital Bladder Diverticulum Presenting as Hypertensive Retinopathy

A congenital bladder diverticulum (CBD) is caused by inherent muscular weakness instead of obstruction of the bladder outlet. The major clinical conditions are recurrent urinary tract infection (UTI) and voiding dysfunction. This report describes a 15-year-old male adolescent who developed sudden visual disturbance resulting from hypertensive retinopathy. The cause of hypertension was bilateral obstructive uropathy caused by enlarged paraureteral bladder diverticula. After the non-functioning right kidney and ureter and the bilateral diverticula were removed, the left ureter was reimplanted in the bladder. Pathologic findings showed chronic pyelonephritis and partial loss of the bladder musculature in the diverticular wall. This observation indicates that dilated CBD can cause latent UTI, ureteral obstruction, hydronephrosis, and secondary hypertension.

Integrated backscatter of hypertensive retinopathy by ultrasonic tissue characterization / 中华超声影像学杂志

Objective To investigate the integrated backscatter(IBS) changes of retina in hypertensive disease patients to offer the reference to clinician for ocular fundus changes of hypertensive disease.Methods One hundred chronic hypertension patients (100 eyes) were divided into 4 groups by clinical stages:① gradeⅠ,28 persons (28 eyes);② grade Ⅱ,27 persons (27 eyes);③ grade Ⅲ,24 persons (24 eyes);④ grade Ⅳ,21 persons (21 eyes).Thirty normal persons of 30 eyes were the control group.Their IBS values were measured on nose side of retina,and the correction IBS values(IBS%) were calculated.Results With the deterioration of hypertensive disease,the IBS(29.48±0.09,32.50±0.04,34.62±0.39,36.48±0.46,37.52±0.43) and IBS%[(68.50±2.11)%,(72.03±0.57)%,(74.29±0.77)%,(76.06±1.43)%,(77.45±0.75)%] of retina were gradually increased.The statistical difference were found among various groups(P=0.000).Conclusions With the deterioration of hypertensive retinopathy,the IBS and IBS% increased gradually.The IBS technique is a useful method to assess the retinopathy of hypertension.

Clinical study of retinal changes in pregnancy induced hypertension / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To determine the prevalence of retinal changes in pregnancy induced hypertension (PIH) patients and to correlate between retinal changes and the severity of disease.METHODS: A cross-sectional observation study was conducted in 100 PIH patients over a period of 6mo (Dec 2014-May 2015).Fundus examination was done in all patients.Fundus changes in right or left or both eyes, was taken as positive.The PIH graded as mild pre-eclampsia (BP >140/90 to 160/90 mmHg), severe pre-eclampsia (BP>160/90 mmHg) and eclampsia (severe pre-eclampsia and convulsions).RESULTS:Mean age was 23.05y(19-34y).Gestation period ranged from 28 to 41wk.Sixty-two were primi gravida and 38 were multigravida.62%, 26%, 12% of patients had mild, severe pre-eclampsia, eclampsia respectively.Retinal changes were identified in 8 patients.Grade Ⅰ, Grade Ⅱ, Grade Ⅲ, Grade Ⅳ hypertensive retinopathy (HTR), serous retinal detachment (SRD) and central serous chorioretinopathy (CSCR) observed in 1%, 0%, 2%, 2%, 1% and 2% of patients respectively.There was a statistically significant positive association of retinal changes and severity of the PIH (P=0.0001).CONCLUSION:Retinal changes were seen in 8% of patients with PIH and there is a positive correlation between retinal changes and severity of PIH.

Lupus Nephritis with Visual Field Defect Secondary to Hypertensive Retinopathy: A Case Report

A 23-year-old lady presented with both eye progressive painless blurring of vision for two weeks in 2011. Prior to that she had malar rash, hair loss, photosensitivity and bilateral leg swelling. Ocular examination showed that visual acuity on the right was 6/60 and on the left was 6/24. Both optic disc were swollen with extensive peripapillary cotton wool spot (CWS), flame shape haemorrhages, dilated and tortuous vessels with macular oedema. Systemic examination revealed blood pressure of 176/111 mmHg, malar rash and alopecia. Diagnosis of grade 4 hypertensive retinopathy secondary to SLE was made. The diagnosis was confirmed by positive ANA/ dsDNA, low C3/ C4 and renal biopsy showed lupus nephritis. She was treated with oral prednisolone, hydroxychloroquine and cyclosporin A. Throughout the monitoring for hydroxychloroquine toxicity, vision over both eyes were 6/9, but serial visual fields showed non-progressive left superior and inferior scotoma while right eye showed inferior scotoma. The intraocular pressure was normal with pink optic disc and cup disc ratio of 0.3. Optical coherence tomography (OCT) showed temporal and nasal retinal nerve fiber layer thinning bilaterally. However, macula OCT, fundus fluorescein angiography and autofluorescence were normal. The visual field defect was concluded secondary to CWS indicating microinfarction of the retinal nerve fiber secondary to previous hypertensive retinopathy. Non-progressive visual field defects may occur after the appearance of CWS in hypertensive retinopathy and it should not be overlooked when diagnosing glaucoma or hydroxychloroquine toxicity.