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.

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

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.

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).

Hidroxicloroquina y retinopatía en pacientes reumatológicos / Hydroxychloroquine use and retinopathy in rheumatologic patients

: relacionar el uso de hidroxicloroquina con la presencia de retinopatía en pacientes reumatológicos. Métodos: se realizó un estudio retrospectivo y descriptivo, de revisión de historias clínicas de pacientes reumatológicos en tratamiento con hidroxicloroquina. Se seleccionaron aquellos con evaluación oftalmológica previa al inicio del tratamiento y estudios como la OCT-SD. Se recolectaron variables clínico epidemiológicas, cálculo de dosis diaria y acumulada del fármaco, y duración del tratamiento. Resultados: se revisaron 150 historias, de las cuales 47 cumplieron con los criterios de inclusión; 44 (93,6%) eran del género femenino y 3 (6,4%) del género masculino. La edad promedio fue de 47 ± 14 años. La hipertensión arterial fue la comorbilidad más frecuente. La patología reumatológica más frecuente fue el Lupus (53,2%). La dosis diaria de hidroxicloroquina fue ≤ 6,5 mg/kg/día en los 47 pacientes; el tiempo promedio de consumo fue de 5 años; y la dosis acumulada promedio fue de 498,5 ± 503,68 gramos. Se detectó toxicidad retiniana en 18 pacientes (38,3%), de los cuales: 17(36,2%) tuvo daño precoz y 1 (2,1%) daño moderado. Se observó relación estadística significativa entre toxicidad retiniana y dosis acumulada menores a 1.000 gramos (p= 0,032) y un tiempo de consumo mayor o igual a 5 años (p = 0,045) Conclusiones: las alteraciones iniciales en las capas externas de la retina ayudan a la detección precoz de toxicidad retiniana por hidroxicloroquina, siendo la OCT-SD un método sensible y fácil de realizar en la práctica clínica(AU)

To establish the relationship between the use of hydroxychloroquine and retinopathies in rheumatologic patients. Methods: This is a retrospective, descriptive study of the medical charts of rheumatologic patients' who were receiving hydroxychloroquine. We selected patients previously seen in ophthalmologic services, and ophthalmologic coherence tomography (SD OCT) had been realized. We collected clinical and epidemiologic variables such as daily doses, accumulated doses and prescription duration. Results: we selected 47 medical charts; the female gender is 44 and three gender male. Mean age was 47 +14 years.Hypertension was the most frequent comorbidity.Lupus was the most frequent rheumatologic illness.Hydroxychloroquine daily dose was < 6.5 mg/Kg/day and treatment`s mean duration was 5 years; average accumulated dosage was 498.5 + 503.68 grs. We established retinal toxicity in 18 patients (38.3%), in which 17 (36.2%) had early damage, and 1(2.1%) had moderated damage. There was a statistical correlation between retinal toxicity and accumulated doses of less than 1.000 grs. (p: 0.032) as well as with time of use > 5 years (p:0.045) Conclusions: Early alterations of retinal superficial layers help in the detection of early retinal toxicity due to hydroxychloroquine use. OCTSD is a feasible and sensible study in daily medical practice(AU)

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.

Retinal changes in solid organ and bone marrow transplantation patients / Alterações retinianas em pacientes de um programa de transplante de órgãos sólidos e de medula óssea

ABSTRACT Objective To evaluate retinal changes in patients who underwent solid organ or bone marrow transplantation. Methods A retrospective analysis of medical records of patients evaluated from February 2009 to December 2016. All patients included underwent funduscopy. Clinical and demographic data regarding transplantation and ophthalmological changes were collected. Results A total of 126 patients were analyzed; of these, 108 underwent transplantation and 18 were in the waiting list. Transplantation modalities were heart, lung, kidney, liver, pancreas, combined pancreas and kidney and bone marrow transplantation. The main pre-transplantation comorbidities were diabetes and arterial hypertension. Of the 108 transplanted patients, 82 (76%) had retinal changes. All patients who underwent pancreas or combined pancreas and kidney transplantation had diabetic retinopathy. The main retinal changes found were diabetic retinopathy, hypertensive retinopathy, retinal vascular occlusions, chorioretinal infections and central serous chorioretinopathy. Conclusion Retinal changes were either related to preexisting conditions, mainly diabetic retinopathy, or developed postoperatively as a complication of the surgical procedure, or as an infection related to the immunosuppressive status, or due to drug toxicity. These patients may present with complex ophthalmological changes and should be carefully evaluated prior to surgery and further followed by an ophthalmologist skilled in the management of diabetic retinopathy and posterior pole infections.

RESUMO Objetivo Analisar as alterações retinianas de pacientes submetidos a transplantes de órgãos sólidos ou de medula óssea. Métodos Análise de prontuário dos pacientes avaliados no período de fevereiro de 2009 a dezembro de 2016. Todos os pacientes incluídos foram submetidos à avaliação fundoscópica. Foram coletados dados demográficos e clínicos, referentes ao transplante e às alterações oftalmológicas encontradas. Resultados Foram avaliados 126 pacientes, sendo 108 submetidos a transplantes e 18 que aguardavam o procedimento. Foram avaliados pacientes submetidos a transplantes de coração, pulmão, rim, fígado, pâncreas, pâncreas-rim e medula óssea. As principais comorbidades pré-transplante foram diabetes e hipertensão arterial. Dos 108 pacientes transplantados, 82 (76%) apresentaram alterações retinianas. Todos os pacientes submetidos ao transplante de pâncreas ou pâncreas-rim apresentaram alterações retinianas relacionadas ao diabetes. As principais alterações retinianas detectadas foram retinopatia diabética, retinopatia hipertensiva, oclusões vasculares retinianas, infecções coriorretinianas e coriorretinopatia serosa central. Conclusão As alterações retinianas estavam relacionadas a doenças preexistentes, principalmente à retinopatia diabética, ou surgiram após o transplante, como complicação do procedimento cirúrgico, ou como complicação infecciosa associada à imunossupressão, ou ainda por toxicidade medicamentosa. Tais pacientes podem apresentar alterações oculares complexas, devendo ser submetidos à avaliação retiniana pré-operatória cuidadosa e ao acompanhamento pós-operatório por oftalmologista especializado no manejo da retinopatia diabética e de doenças infecciosas do segmento posterior ocular

Clinical Features of Pregnancy-associated Retinal and Choroidal Diseases Causing Acute Visual Disturbance

PURPOSE: To report clinical features of patients with retinal and choroidal diseases presenting with acute visual disturbance during pregnancy. METHODS: In this retrospective case series, patients who developed acute visual loss during pregnancy (including puerperium) and visited a tertiary hospital from July 2007 to June 2015, were recruited by searching electronic medical records. Patients were categorized according to the cause of visual loss. Clinical features and required diagnostic modalities were analyzed in the retinal and choroidal disease group. RESULTS: Acute visual loss occurred in 147 patients; 49 (38.9%) were classified into the retinal and choroidal group. The diagnoses included central serous chorioretinopathy (22.4%), hypertensive retinopathy with or without pre-eclampsia (22.4%), retinal tear with or without retinal detachment (18.4%), diabetic retinopathy progression (10.2%), Vogt-Koyanagi-Harada disease (4.1%), retinal artery occlusion (4.1%), multiple evanescent white dot syndrome (4.1%), and others (14.3%). Visual symptoms first appeared at gestational age 25.9 ± 10.3 weeks. The initial best-corrected visual acuity (BCVA) was 0.27 ± 0.39 logarithm of the minimum angle of resolution (logMAR); the final BCVA after delivery improved to 0.13 ± 0.35 logMAR. Serious visual deterioration (BCVA worth than 20 / 200) developed in two patients. Differential diagnoses were established with characteristic fundus and spectral-domain optical coherence tomography findings in all cases. CONCLUSIONS: In pregnant women with acute visual loss, retinal and choroidal diseases are common and could be vision threatening. Physicians should be aware of pregnancy-associated retinal and choroidal diseases and their clinical features. The differential diagnosis can be established with non-invasive techniques.

Medición de la microcirculación retiniana luego del tratamiento antihipertensivo / Measuring retinal circulation after antihypertensive treatment

Background and objective: With the development of image processing techniques, it has become possible to measure the changes in retinal vessels of hypertensive patients by means of eye fundus photographs. Patients and method: In this paper we aim to classify retinal vessels automatically into arterioles and venules. In order to do so, we have compared three different strategies based on the colour of the pixels in images through an analysis of 78 hypertensive patients' eye fundus images. The first strategy classifies all the vessels by applying a clustering algorithm. The second divides the retinal image into four quadrants and classifies the vessels that belong to the same quadrant independently from the rest of the vessels. The third strategy classifies the vessels by dividing the retinal image into four quadrants that are rotated inside the mentioned image. Results: The third strategy was the one that obtained the best results, since it minimizes the number of unclassified vessels. In the initially analysed set of 20 images, we correctly classified 86.53% of the vessels, and this percentage remains similar in a set of 58 images examined by three medical experts. This confirms the validity of the method that automatically calculates the arteriovenous ratio (AVR).Conclusion: Our results are an improvement on those previously described in the bibliography, reducing the number of non-classified vessels. Furthermore, the method entails low computational costs.

Fundamento y objetivo: El desarrollo de técnicas de procesado de imágenes ha devuelto interés para poder medir de una forma objetiva los cambios en la estructura microvascular del hipertenso a través de las fotografías digitales del fondo de ojo. Pacientes y método: Para clasificar de forma automática los vasos de la retina en arteriolas y vénulas, con una elevada precisión, hemos comparado tres estrategias diferentes basadas en la información del color de los pixeles de la imagen del fondo de ojo, analizando 78 imágenes de fondo de ojo de hipertensos. La primera estrategia clasificaría todos los vasos aplicando un algoritmo de agrupamiento. La segunda divide la retina en cuatro cuadrantes y clasifica los vasos que pertenecen al mismo cuadrante independientemente del resto de los vasos. La tercera estrategia clasifica los vasos dividiendo la retina en cuadrantes que son rotados. Resultados: La mejor estrategia resultó la tercera porque minimiza el error y el número de vasos no clasificados. La característica vectorial más determinante está basada en la media o la mediana del componente gris del espacio de color RGB. Para las 20 imágenes inicialmente analizadas hemos clasificado correctamente el 86.53% de los vasos, y este porcentaje permanece similar en el grupo de 58 imágenes examinadas por tres expertos, lo que confirma la validez del método, para el cálculo del índice arteriovenoso de forma automática. Conclusión: Nuestros resultados son superiores a los descritos previamente, reduciendo además el número de vasos no clasificados. Por otro lado, el costo computacional del método es bajo

Confirmación diagnóstica y frecuencia de patrón angiográfico de coroidoretinopatía serosa central en Bogotá (Colombia) / Diagnostic confirmation and angiography pattern frequency of Central Serous Coroidoretinopathy in Bogotá (Colombia)

Objetivo: El propósito de este estudio es determinar la cifra de confirmación diagnóstica de coroidoretinopatía serosa central durante Junio 2012 a Noviembre 2013, describir la frecuencia de los diferentes patrones angiográficos y características como sexo, ocupación, edad y antecedentes médicos más frecuentes. Materiales y Métodos: Se realizó un estudio observacional descriptivo. Con la revisión de la historia de ingreso y reporte del resultado de 71 pacientes que asistieron al centro de diagnóstico Angiografía Digital SAS, de Bogotá (Colombia) para la realización del examen retinal angiografía fluoresceínica en ambos ojos con criterio de inclusión de impresión diagnóstica clínica de Coroidoretinopatía Serosa Central. Se utilizó el programa SPSS Versión 21, para realizar el análisis estadístico de los datos obtenidos. Resultados: Se encontró que en 74.3% (52 pacientes) se confirmó la enfermedad, en 25,7% (18 pacientes) se descartó la presencia de Coroidoretinopatía Serosa Central. Se excluyó 1 paciente por datos incompletos. El patrón angiográfico más frecuente fue de puntos expansivos 80.8% (42 pacientes), seguido en frecuencia por el patrón en humo de chimenea 15.4% (8 pacientes) y por último el patrón difuso 3.8% (2 pacientes). Estos resultados se presentaron con mayor frecuencia en hombres que en mujeres, las ocupaciones más frecuentes fueron independiente-comerciante y profesionales en salud, el rango de edad más frecuente fue de 41 a 45 años y la mayoría de los pacientes no presentaron antecedentes médicos. Conclusión: En nuestro medio demográfico de Bogotá (Colombia) se confirma la impresión diagnóstica clínica de Coroidoretinopatía serosa Central en 74,3% con el examen de Angiografía fluoresceínica de retina para un total de 70 pacientes que consultaron en un periodo de 16 meses. El patrón angiográfico más frecuente es de puntos expansivos 80,8%, a pesar que el patrón angiográfico patognomónico y más conocido por la sociedad médica oftalmológica es el de humo de chimenea.

Objective: The purpose of this study was to determine the diagnostic confirmation of central serous chorioretinopathy during June 2012 to November 2013, the frequency of different angiographic patterns and demographic characteristics such as gender, occupation, age and medical history. Materials and Methods: A descriptive study was conducted. With the revision of the clinical record and reports of 71 patients who attended the diagnostic center Angiografía Digital SAS, Bogota (Colombia) for the realization of retinal fluorescein angiography examination in both eyes that met the inclusion criteria of clinical diagnostic impression of Central serous choroidopathy. SPSS version 21 program was used to perform the statistical analysis of the data obtained. Results: In this setting the confi rmation of CSC with angiography was 74.3% (52 patients) and in 25.7% (18 patients) the presence of Central Serous Chorioretinopathy was discarded. One patient was excluded because of incomplete data. The most common angiographic pattern was expansive points 80.8% (42 patients), followed in frequency by the smoke-stack pattern in 15.4% (8 patients) and fi nally the diffuse pattern 3.8% (2 patients).CSC occurred more often in men than in women, the most common occupations were independent and health-related occupations, the most common age range was 41-45 years and there was no frequent report of medical problems. Conclusion: In our geographic setting the clinical diagnosis of central serous chorioretinopathy was confi rmed in 74,3% of the cases with fl uorescein angiography for 70 patients seen in a lapse of time of 16 months. The most frequent angiography pattern was expansive dots in contrary to the most known pattern of smoke-stack pattern.

Window to Heart; Ocular Manifestations of Hypertension / 한양의대학술지

Systemic hypertension affects not only the heart, kidneys, brain, and large arteries but also the eyes. High blood pressure (BP) causes a series of pathophysiological changes in the retinal vasculature, including focal and diffuse narrowing of the retinal arteriole, opacification of the arteriolar wall, and compression of the venules by arterioles. In severe cases, hemorrhage, nerve fiber layer infraction, and disc swelling can occur. Systemic hypertension results in various retinal vascular diseases, such as hypertensive retinopathy, retinal vein or artery occlusion, retinal arterial macroaneurysm, and nonarteritic ischemic optic neuropathy. High BP also increases the risk of development and progression of diabetic retinopathy. Signs of hypertensive retinopathy are predictive of target-organ damages, including cardiovascular and cerebrovascular diseases. While managing patients with hypertensive retinopathy, physicians should be aware of the management of cardiovascular and cerebrovascular risk factors.

Síndrome de encefalopatía posterior reversible con afectación del tronco cerebral y médula espinal y retinopatía hipertensiva grado IV / Posterior reversible encephalopathy syndrome with brain stem and spinal cord involvement and grade iv hypertensive retinopathy

El síndrome de leucoencefalopatía posterior reversible se presenta con síntomas de edema cerebral e imágenes hiperintensas en las secuencias T2 y FLAIR en la resonancia magnética (RM) de cerebro. Las lesiones típicamente comprometen la región parietooccipital, aunque también pueden tener localizaciones atípicas. Presentamos el caso de una mujer de 33 años que consultó por trastornos visuales asociados con dolor de cabeza intenso e hipertensión grave (220/140 mmHg). El examen del fondo de ojo reveló retinopatía hipertensiva grado IV y la RM mostró lesiones hiperintensas en T2 y FLAIR a nivel centropontino, bulbo y médula espinal, las cuales regresaron tras el control sostenido de la presión arterial. (AU)

The posterior reversible leukoencephalopathy syndrome presents with symptoms of cerebral edema. On magnetic resonance imaging (MRI) of the brain, hyperintensities on T2 -weighted and FLAIR sequences typically affect the parietal-occipital region; however it may also have atypical locations. We report the case of a 33 year old patient with visual disturbances associated with intense headache and severe hypertension (220/140 mmHg). The Fundus examination revealed grade IV hypertensive retinopathy, and MRI showed hyperintense lesions in T2 and FLAIR affecting the pontine center, medulla and spinal cord, which regressed after sustain blood pressure control. (AU)

Quality of Life on Arterial Hypertension: Validity of Known Groups of MINICHAL / Qualidade de Vida na Hipertensão Arterial: Validade de Grupos Conhecidos do MINICHAL

Introductions: In the care of hypertension, it is important that health professionals possess available tools that allow evaluating the impairment of the health-related quality of life, according to the severity of hypertension and the risk for cardiovascular events. Among the instruments developed for the assessment of health-related quality of life, there is the Mini-Cuestionario of Calidad de Vida en la Hipertensión Arterial (MINICHAL) recently adapted to the Brazilian culture. Objective: To estimate the validity of known groups of the Brazilian version of the MINICHAL regarding the classification of risk for cardiovascular events, symptoms, severity of dyspnea and target-organ damage. Methods: Data of 200 hypertensive outpatients concerning sociodemographic and clinical information and health-related quality of life were gathered by consulting the medical charts and the application of the Brazilian version of MINICHAL. The Mann-Whitney test was used to compare health-related quality of life in relation to symptoms and target-organ damage. The Kruskal-Wallis test and ANOVA with ranks transformation were used to compare health-related quality of life in relation to the classification of risk for cardiovascular events and intensity of dyspnea, respectively. Results: The MINICHAL was able to discriminate health-related quality of life in relation to symptoms and kidney damage, but did not discriminate health-related quality of life in relation to the classification of risk for cardiovascular events. Conclusion: The Brazilian version of the MINICHAL is a questionnaire capable of discriminating differences on the health‑related quality of life regarding dyspnea, chest pain, palpitation, lipothymy, cephalea and renal damage. .

Fundamento: No cuidado ao hipertenso, é importante que o profissional de saúde disponha de ferramentas que possibilitem avaliar o comprometimento da qualidade de vida relacionada à saúde, de acordo com a gravidade da hipertensão e o risco para eventos cardiovasculares. Dentre os instrumentos criados para avaliação da qualidade de vida relacionada à saúde, destaca-se o Mini-Cuestionario de Calidad de Vida en la Hipertensión Arterial (MINICHAL), recentemente adaptado para a cultura brasileira. Objetivo: Estimar a validade de grupos conhecidos da versão brasileira do MINICHAL em relação à classificação de risco para eventos cardiovasculares, sintomas, intensidade da dispneia e lesões de órgãos-alvo. Métodos: Foram investigados 200 hipertensos em seguimento ambulatorial, cujos dados sociodemográficos, clínicos e de qualidade de vida relacionada à saúde foram obtidos por meio de consulta ao prontuário e da aplicação da versão brasileira do MINICHAL. O teste de Mann-Whitney foi utilizado para comparar qualidade de vida relacionada à saúde em relação aos sintomas e às lesões de órgãos-alvo. Teste de Kruskal-Wallis e ANOVA com transformação nos ranks foram empregados para comparar qualidade de vida relacionada à saúde em relação à classificação de risco para eventos cardiovasculares e intensidade da dispneia, respectivamente. Resultados: O MINICHAL discriminou qualidade de vida relacionada à saúde em relação aos sintomas e dano renal (lesões de órgãos-alvo), porém não discriminou qualidade de vida relacionada à saúde em relação à classificação de risco para eventos cardiovasculares. Conclusão: A versão brasileira do MINICHAL é um instrumento capaz de discriminar diferenças na qualidade de vida relacionada à saúde em relação aos sintomas de dispneia, precordialgia, palpitação, lipotímia, cefaleia e presença de dano renal. .

Um novo olhar da retinopatia hipertensiva: a aplicação prática de novas tecnologias / A new look at hypertensive retinopathy: the practical application of new technologies

O exame de fundo de olho tem importância histórica e mantém sua relevância nos dias atuais, por possibilitar de maneira não invasiva, observar e avaliar o “interior” do corpo humano, além de ser um importante marcador de lesão de órgão-alvo em hipertensos. O surgimento de tecnologias de aquisição de imagens digitais permitiu acessar o fundo de olho de maneira mais simples, com grande definição, muitas vezes não necessitando dilatação da pupila. Isso tornou a observação do fundo de olho, que outrora era realizada apenas por pessoas com treinamento especial, fosse feita com extrema facilidade e quase sem treinamento. Estas “facilidades” permitiram que inúmeros artigos científicos fossem realizados, estabelecendo características do fundo de olho como relevante marcador de lesão de órgão-alvo em hipertensos. A incorporação de tecnologias virtuais na prática da medicina facilitará o acesso dos pacientes, reduzirá custos e certamente irá revolucionar a relação médico-paciente nos próximos anos.

Eye fundus examination is of historical importance, and maintains its relevance nowadays, by enabling non-intrusive observation and evaluation “inside” the human body, as well as being an important marker of target organ damage in hypertensive patients. The emergence of technologies for digital image acquisition have enabled easier access to the eye fundus, with greater definition, and often without having to dilate the pupil. As a result, eye fundusexamination, once carried out only by people with special training, is now performed with extreme ease and almost no training. These “facilities” have led to numerous scientific articles, establishing the characteristics of the eye fundus as a relevant marker of target organ damage in hypertensive patients. The incorporation of virtual technologies into the practiceof medicine will facilitate patient access, reduce costs, and without doubt, revolutionize the doctor-patient relationship in the coming years.

Associação dos achados morfofuncionais cardíacos, renais e vasculares com as alterações do índice tornozelo-braço em pacientes hipertensos diabéticos / Association of cardiac, renal and vascular morphological and functional findings with changes in ankle brachial index in diabetic hypertensive patients

Introdução: Inúmeros estudos estabeleceram correlações entre o índice tornozelo-braço (ITB), um marcador de aterosclerose subclínica, e o prognóstico cardiovascular em diferentes populações. No entanto, poucos estudos avaliaram a correlação entre os valores do ITB e lesões cardiovasculares e renais, exclusivamente, em pacientes com hipertensão arterial e diabetes. Objetivo: Estudar a prevalência de alterações morfofuncionais cardíacas, carotídeas, retinianas e renais de acordo com a presença ou não de valores de ITB alterados (ITB <= 0,9 ou ITB > 1,4) em pacientes hipertensos com diabetes tipo 2. Métodos: Foram incluídos no estudo 99 pacientes hipertensos diabéticos com idade entre 50 e 80 anos. A aferição do ITB foi realizada em todos os pacientes por método validado e estes foram classificados em Grupo 1 (ITB normal, n = 49) ou Grupo 2 (ITB alterado, n =50). Todos os pacientes foram submetidos, em até 06 meses, à realização de ecodopplercardiograma, ultrassonografia de carótidas, retinografia colorida, aferição da taxa de filtração glomerular (TFG) e da albuminúria de 24h. Os pacientes foram analisados para a ocorrência ou não de um desfecho-composto ecocardiográfico que incluiu alterações morfológicas e funcionais cardíacas relevantes para a prática clínica. Os pacientes dos grupos 1 e 2 foram também comparados quanto à prevalência de placas carotídeas com ou sem repercussão hemodinâmica, TFG < 60 ml/mim/m2, albuminúria de 24h > 30mg e presença ou não de retinopatia. Por fim, foram comparadas as frequências médias das seguintes lesões de órgãos-alvo de ambos os grupos, considerando-se valor unitário para a presença de cada uma delas: hipertrofia do ventrículo esquerdo, retinopatia hipertensiva, TFG < 60 ml/min/m2 e estenose da artéria carótida interna > 50% do seu diâmetro. Resultados: A média de idade dos pacientes foi 65,4 ± 7 anos, sendo 61,6% deles do sexo feminino. A presença de níveis elevados de pressão arterial sistólica...

Introduction: A lot of studies have established strong correlations between the ankle-brachial index (ABI), a marker of subclinical atherosclerosis and cardiovascular prognosis in different populations. However, few studies have assessed the correlation between the values of the ABI and cardiovascular and renal lesions in patients with hypertension and diabetes. Objective: To study the prevalence of cardiac, carotid, renal and retinal morphological and functional changes according to the presence or not of altered ABI values (ABI <= 0.9 or ABI > 1.4) in hypertensive patients with type 2 diabetes. Methods: It was included 99 diabetic hypertensive patients aged between 50 and 80 years. The measurement of the ABI was performed in all patients by validated method and they were classified in Group 1 (normal ABI, n = 49) or group 2 (altered ABI, n = 50). All patients were submitted, up to 6 months, to Doppler echocardiography, carotid ultrasound, color retinography, assessment of glomerular filtration rate (GFR) and 24h albuminuria. Patients were analyzed for the occurrence or not of a composite echocardiographic outcome which included morphological and functional cardiac alterations relevant to clinical practice. Patients in groups 1 and 2 were compared regarding the prevalence of carotid plaques with or without hemodynamic repercussion, TFG < 60 ml/min/m2, 24h albuminuria > 30 mg and the presence or not of retinopathy. Finally, we compared the prevalence of mean frequency of the following end-organ lesions of both groups, considering unit value for each one: left ventricular hypertrophy, hypertensive retinopathy, TFG < 60 ml/min/m2 and internal carotid artery stenosis > 50%. Results: The mean age of the patients was 65.4 ± 7 years, with 61.6% of them female. The presences of elevated levels of systolic blood pressure (153.4 ± 18 versus 170.0 ± 26 mmHg), of 24h albuminuria > 30 mg (55.3% versus 82.6%) and TFG < 60 ml/min/m2 (12.8% vs. 33.3%) were significantly...

Emergências hipertensivas: epidemiologia, definição e classificação / Hypertensive emergencies: epidemiology, definition and classification

Embora vários termos tenham sido aplicados para hipertensão grave, tais como crise hipertensiva, emergências ou urgências, todos eles são caracterizados por elevações agudas da pressão arterial que podem estar associados com lesão de órgão-fim (crise hipertensiva). Práticas de tratamento variam consideravelmente por causa da falta de evidências que suportam o uso de um agente terapêutico em detrimento de outro. O objetivo desta revisão foi analisar a fisiopatologia das crises hipertensivas comumente encontradas, incluindo acidente vascular cerebral (AVC), encefalopatia hipertensiva, dissecção aórtica, edema pulmonar agudo e pré-eclâmpsia/eclâmpsia, e fornecer uma abordagem racional para o seu tratamento com base em princípios fisiopatológicos e farmacológicos relevantes.

Although various terms have been applied to severe hypertension, such as hypertensive crisis, emergencies, or urgencies, they are all characterized by acute elevations in blood pressure that may be associated with end-organ damage (hypertensive crisis). Treatment practices vary considerably to because of the lack of the evidence supporting the use of one therapeutic agent over another. The purpose of this review is to examine the pathophysiology of commonly encountered hypertensive crises, including stroke, hypertensive encephalopathy, aortic dissection, acute pulmonary edema and preeclampsia/eclampsia and to provide a rational approach to their treatment based upon relevant pathophysiologic and pharmacologic principles

Retinopatia em pacientes hipertensos e/ou diabéticos em uma unidade de saúde da família / Retinopathy in patients with hypertension and/or diabetes in a family health unit

Objetivo: Identificar a prevalência de alterações à oftalmoscopia direta em pacientes com diagnóstico de hipertensão e/ou diabetes mellitus em uma Unidade de Saúde da Família (USF). Método: Estudo individual, observacional, prioritariamente descritivo, do tipo transversal, com amostra composta por coorte de 50 pacientes hipertensos e/ou diabéticos matriculados no programa HIPERDIA de uma Unidade de Saúde Familiar (USF) do município de Ananindeua - Pará, entre os meses de setembro e novembro de 2009. Resultados: Foi realizada oftalmoscopia em 46 pacientes. Observou-se alteração à oftalmoscopia em 27 (58,7%). Ao realizar a análise específica (excluindo-se os achados de estreitamento arteriolar e ingurgitamento venoso) houve alterações em 18 (39,1%), sendo 45,5% com DM e HAS, quarenta por cento com DM e 36% com HAS. Conclusão: A elevada prevalência de alterações à oftalmoscopia encontradas no presente estudo demonstra sua eficácia como método de rastreio no contexto da atenção primária a saúde, justificando seu uso. Corrobora, ainda, a importância da atenção primária à saúde na prevenção da retinopatia hipertensiva e diabética, através do controle periódico de pacientes de alto risco vascular como a população estudada. .

Purpose: To identify the prevalence of abnormal ophthalmoscopy in patients with systemic hypertension (SH) and / or diabetes mellitus (DM) in a Family Health Unit (FHU). Method: was performed a individual study, observational, primarily descriptive and crosssectional of a sample of a cohort of 50 patients with hypertension and / or diabetic enrolled in the program HIPERDIA in a FHU of the city of Ananindeua - Para, between the months of september and november 2009. Results: ophthalmoscopy was performed in 46 patients and 27 (58.7%) had some alteration. When performing a specific analysis (excluding the findings of arteriolar narrowing and venous engorgement) were changes in 18 (39.1%), 45.5% with DM and SH, 40% with DM and 36% with SH. Conclusion: The high prevalence of the changes in ophthalmoscopy found in this study demonstrates that effectiveness as a screening method in the context of primary health care, justifying that use. corroborates also the importance of primary care in the prevention of diabetic and hypertensive retinopathy, through periodic control of patients at high vascular risk as the population studied. .