Features of development and approaches to treatment of hypertensive angiopathy. What is hypertensive angiopathy and how to treat it Hypertensive type angiopathy

Constantly elevated blood pressure harms the vascular system. Retinal angiopathy of the hypertensive type is caused by a strong narrowing of small veins and arteries, which change their structure over time. The disease can result in a significant decrease in vision until it is completely lost if treatment is not started in a timely manner. Therapy consists of normalizing blood pressure levels, using medications for the eye vessels, physiotherapy, herbal remedies, and correcting habits and nutrition.

Etiology and pathogenesis

Chronic hypertension, when the systolic reading exceeds 140 and the diastolic reading exceeds 90 mm Hg. Art. causes pathological changes in the blood vessels of the whole body, including the eyes. Spasmed small capillaries and arteries of the retina impede normal blood circulation and the flow of nutrients. Ocular angiopathy accompanies long-term hypertension of any type. It is detected more often after 30 years of age, but is sometimes diagnosed in young people and children. Congenital disorders of the retinal vessels, chronic diseases, bad habits, excess weight, physical and emotional overload, poor nutrition, and physical inactivity contribute to the appearance of angiopathy. The pathological process develops gradually.

Pathogenesis of eye angiopathy

Stages	What is being observed?
Functional disorders	Veins dilate, arteries narrow
	Microcirculation is disrupted
	Symptoms are mild
	Changes are noticeable only when examining the fundus
	The walls of blood vessels become denser
Organic changes	A characteristic shine of blood vessels appears
	The blood supply to the retina is impaired
	Thinned and fragile arteries and branched veins are observed
	Hemorrhages occur
Hypertensive retinopathy	A critical failure of blood circulation is detected
	Inflammatory exudate is formed
	Possible thrombosis and vascular sclerosis
	Frequent hemorrhages occur
	Swelling of the retina and optic nerve is noticeable

Damage to the retina worsens under the influence of metabolic dysfunctions, due to osteochondrosis of the neck and disturbances in the properties and composition of the blood, with deficiency of nutrition of the eyeball and age-related changes.

Symptoms of the disease

In such patients, vision decreases rapidly.

Hypertensive angiopathy of retinal vessels progresses slowly. In the first stages of its development, a person does not feel any significant discomfort. Gradually, the patient's vision begins to lose clarity. The vessels of both eyes are affected. The intensity of symptoms depends on the degree of destructive vascular deformations of the retina. All manifestations of the disease are accompanied by high blood pressure. Signs of ocular vascular angiopathy in hypertension:

• deterioration of vision - a “veil” before the eyes, a cloudy and blurry picture;
• progress of myopia;
• fatigue and eye strain;
• periodic appearance of flashes and black spots;
• decreased peripheral vision;
• headache;
• sensations of pulsation in the eyes;
• nosebleeds;
• capillary network, yellow spots on the sclera;
• pain in the legs.

Complications

The disease leads to fragility of blood vessels and frequent hemorrhages.

The combination of pathological processes in the retina of the eyes, which are caused by hypertensive disease, leads to dangerous consequences if the treatment is untimely and incorrectly selected. Obstruction of blood flow in the small vessels of the retina leads to tissue ischemia. Oxygen starvation makes arteries fragile, they often burst and hemorrhages occur. The optic nerve also experiences nutritional deficiency. Fatty deposits are deposited in the lumens of blood vessels and blood clots form. This process affects both the central ophthalmic artery and its branches. ultimately leads to the most dangerous complication - retinal detachment, causing complete blindness.

Diagnostic procedure

Detection of early disorders of the structure of retinal vessels caused by hypertension is complicated by the fact that patients turn to an ophthalmologist already at the stage of the onset of organic deformations. Detection of pathology in the early phases during preventive eye examinations is very rare. Hypertensive retinal angiopathy is diagnosed based on the clinical picture and in the presence of a history of hypertension. After checking visual acuity and examining the fundus of the eye, the ophthalmologist prescribes additional examinations, such as:

• ophthalmochromoscopy - checking the blood vessels of the eye under rays of white and red light;
• Ultrasound of the eyeball;
• rheoophthalmography - assessment of blood circulation;
• angiography of retinal vessels;
• laboratory tests of urine and blood;
• blood pressure monitoring;

Treatment of retinal vascular disorders

For such pathology, it is useful to take an infusion of horsetail.

The key direction in eliminating pathology is the fight against the underlying disease - arterial hypertension. Complex therapy is used, including medications to lower blood pressure, eliminate symptoms of damage to the ocular vessels and prevent complications. Physiotherapy procedures will help to activate blood flow, reduce IOP, and ease vasospasm. Laser or magnetic influences are prescribed. Among the folk remedies, it is useful to brew and drink infusions of white mistletoe, horsetail with hawthorn, a collection of St. John's wort, chamomile, immortelle, birch buds, and yarrow. The doctor always focuses on improving lifestyle for quality therapy. You will need to follow a diet limited in fat and reduce fluid intake. Hypertensive angiopathy of the retina of both eyes is treated using such groups of medications as:

• Antihypertensive medications:
  • beta blockers;
  • ACE inhibitors;
  • diuretics;
• Antithrombotic:
  • "Clopidogrel";
  • "Magnicor".
• Restoring microcirculation in the eyes:
  • "Emoxipin":
  • "Solcoseryl".
• Vessel strengthening agents:
  • preparations based on ginkgo biloba;
  • "Parmidine."
• Absorbing exudate on the retina:
  • "Papain".
• Eye drops:
  • "Taufon";
  • "Quinax."
• Vitamins:
  • "Aevit";
  • "Blueberry Forte".

Patients with damage to retinal vessels due to hypertension should visit an ophthalmologist, general practitioner and cardiologist twice a year.

Under the influence of a provoking factor (high blood pressure), the vascular wall thickens, the lumen narrows, and the arterioles cannot deliver oxygen to the tissues. Oxygen starvation, which is called hypoxia, leads to dysfunction of the visual organs. As a result, the retina suffers, and lack of treatment can cause blindness.

Causes

Hypertensive angiopathy develops as a result of uncontrolled and intractable high blood pressure. Especially if the patient ignores the problem for many years.

Several risk factors contribute to the development of hypertension in a person. They are divided into:

• managed – physical inactivity and sedentary lifestyle, excessive consumption of salt, fatty foods, alcohol, smoking, stress, obesity;
• uncontrollable – family history, female gender, age.

Arterial hypertension is of two types:

• primary (true hypertension) - manifests itself in older people who have no other reasons for hypertension;
• secondary (symptomatic) - first diagnosed in young people and is a symptom of another, underlying disease (systemic vasculitis, pheochromocytoma, thyrotoxicosis, primary aldosteronism).

Symptoms

At the beginning of the course of hypertensive retinal angiopathy, there are almost no symptoms, and morphological changes in the fundus can only be detected with hardware diagnostics. When clinical manifestations begin, the patient complains of discomfort in both eyes at the same time.

In the initial stages, there is a decrease in visual acuity, flickering, and a veil before the eyes. Symptoms regress after an attack, but in later stages this leads to an irreversible decrease in vision up to complete loss. The attacks are accompanied by headache, dizziness, and tinnitus. Retinal hemorrhages and nosebleeds are possible.

Classification of fundus changes

The following classification is distinguished :

• hypertensive angiopathy;
• hypertensive angiosclerosis;
• hypertensive retinopathy.

Hypertensive angiopathy may not have clinical symptoms, but is detected only during a medical examination by an ophthalmologist. In the fundus, the doctor sees a narrowing of the retinal arteries.

Hypertensive angiosclerosis is manifested by sclerosis (thickening) of the walls of blood vessels, reducing their lumen until it completely overlaps. In the fundus, the doctor sees a change in the color of the arterioles, which become whitish and can compress the veins.

With hypertensive retinopathy (angioretinopathy), there are changes in both the blood vessels and the retina itself. Upon examination, inflammatory exudate (liquid secreted) and areas of hemorrhage in the fundus are detected. At this stage, the patient complains of a significant decrease in vision or blindness.

Which doctor treats hypertensive angiopathy

This disease is treated by an ophthalmologist. Due to the fact that hypertensive angiopathy is a complication of hypertension, the patient should be regularly monitored by a therapist or cardiologist. They will correct blood pressure levels, which will improve the results of treatment by the ophthalmologist.

Diagnostics

Diagnostic measures must be carried out comprehensively and in full. First, you should contact a therapist who will diagnose and treat the underlying disease (essential or secondary hypertension).

He will refer the patient for a consultation with an ophthalmologist, who will begin the examination with an examination of the fundus of the eye (ophthalmoscopy) and visual acuity. An ultrasound examination of the vessels of the head and neck should also be performed to determine the nature of the blood flow. Other types of examinations are prescribed individually according to indications.

Treatment

Antihypertensive drugs remove excess fluid from the body. As a result, the volume of circulating blood decreases and the narrowing of peripheral vessels is prevented.

For this purpose, therapy is prescribed with the following groups of drugs:

• diuretics (Furosemide, Indapamide);
• ACE inhibitors/Sartans (lisinopril, Valsartan);
• β-blockers (Atenolol);
• Ca channel blockers (Amlodipine).

When treating hypertensive retinal angiosclerosis, it is necessary to normalize blood pressure numbers. The doses of medications used can be increased by the doctor so that the effect becomes more noticeable.

Hypertensive angiopathy is treated symptomatically. For this purpose, medicinal substances are used that promote the resorption of hemorrhages (Potassium iodide drops), improve microcirculation and restoration of the retina (Taufon).

Both tablet preparations (Curantil, Ginkgo biloba) and parenteral administration of systemic drugs are used. The latter include Mildronate, Actovegin, vitamins (nicotinic acid). They improve tissue trophism and metabolic processes throughout the body.

Prevention

Angioretinopathy is a dangerous disease, so it is easier to prevent it than to cure it. First, you should minimize all risk factors:

• control body weight;
• limit animal fats and easily digestible carbohydrates in the diet;
• reduce salt intake to 5 g per day;
• give up bad habits (smoking, alcohol);
• engage in moderate physical activity, for example, walking at a fast pace, swimming;
• limit physical overexertion (football, weight lifting);
• reduce emotional stress.

Uncontrolled hypertension can cause serious complications, including hypertensive angiopathy. It significantly reduces the patient's quality of life and can lead to blindness. Carrying out preventive measures, regularly visiting a doctor and following all his recommendations will help prevent complications or improve the prognosis for recovery.

Useful video about hypertensive angiopathy

15.09.2017

Arterial hypertension (AH), that is, a persistent increase in blood pressure, is a common phenomenon that can occur in a benign or malignant form. Malignant hypertension is accompanied by damage to some target organs.

One of these organs that can be affected by hypertension is the eyes. The interaction of the ocular vessels with high blood pressure is dangerous, since it is not the gas itself that is damaged, but its retina. The danger is that this leads to loss of vision in the shortest possible time, without the possibility of recovery.

Hypertensive angiopathy of retinal vessels

This pathological condition is called hypertensive angiopathy and retinopathy. Angiopathy of the retina of both eyes is a pathological change in the structure of the blood vessels of the fundus of the eye. Retinal angiopathy of the hypertensive type is a common chronic disease during which the retinas of both eyes are affected and their functioning is impaired. Therefore, it is important to start treatment at the initial stage of the disease and prevent complications. Hypertensive retinal angiopathy: what is it, why does the pathology develop and how can it be cured? It is recommended that every person suffering from hypertension know this.

Stages of hypertensive retinopathy

Depending on the degree of damage to the retinal vessels, hypertensive angiopathy of the retinal vessels develops in several stages. And exactly what stage of the disease in a particular case can be determined by an ophthalmologist after examining the fundus. Depending on the degree of development of the pathology, certain disorders of the blood vessels of the eye occur. There are 4 stages of development of hypertensive retinopathy:

• first stage. Physiological changes occur, but there are no significant symptoms. The person does not experience discomfort and does not even realize there is a problem. Vascular spasm and expansion of the lumen of the ocular arteries occurs very slowly, so the disease can only be determined during an examination by an ophthalmologist;
• second stage. Organic changes occur in the walls of blood vessels. The symptoms become more pronounced and begin to cause inconvenience to the person, which is why the first complaints arise. During the examination, the doctor notices expansion, swelling of the venous network, pinpoint hemorrhages, shine of the vascular walls and waxy pallor of the fundus;
• third stage. In the structure of the retina and directly in the vessels, degenerative processes begin to occur with great intensity, which can provoke retinal detachment;
• fourth stage. This is the final stage of development of angiopathy of the ocular retina, which is accompanied by the release of fluid that accumulates in the fundus of the eye as a result of the inflammatory process and as a consequence of impaired blood circulation to an advanced degree.

At the first stage, it is possible to simply prevent the development of consequences, but if you start the development of the pathological process, then loss of vision is guaranteed. Therefore, you need to undergo a routine examination with doctors, including an ophthalmologist. And if a problem is detected, it is recommended to begin treatment as quickly as possible and follow the instructions of the attending physician.

Etiology of retinal angiopathy

The cause of hypertensive angiopathy of the retina is arterial hypertension, increased blood pressure, which can develop due to:

• constant exposure to stressful situations;
• nervous, emotional or physical stress;
• hereditary predisposition;
• sedentary lifestyle;
• pathologies of the cardiovascular system;
• hormonal imbalances.

There are many reasons for the development of hypertension, and the etiology of hypertension is not yet fully understood. And since the symptoms of arterial hypertension are not specific, many do not pay any attention to dizziness, weakness and other signs of high blood pressure, attributing everything to ordinary fatigue. And this is very bad, because a person often resorts to medical help only when serious changes begin to develop, among which hypertensive angiopathy of the retina is often encountered. There are a number of factors contributing to the development of the disease:

• congenital vascular defects of the eyes;
• smoking and alcohol;
• overweight, obesity;
• various harmful production factors;
• diseases of various nature;
• diabetes;
• a disrupted diet, in which fats and carbohydrates predominate.

The severity of the pathological process also depends on several reasons:

• duration of hypertension;
• presence of toxic substances in the environment;
• features of professional activity associated with constant eye strain;
• various background diseases.

In several people with the same degree and duration of hypertension, retinal angiopathy will be expressed to varying degrees. This pathology can develop in any person suffering from a persistent increase in blood pressure, but still this phenomenon is most often detected in young men, aged 30-40 years. But often this phenomenon also affects pregnant women.

Symptoms of hypertensive angiopathy

The degree of development of arterial hypertension does not affect the appearance of retinal angiopathy. And this pathology can develop in the same way, both after prolonged high blood pressure and after a strong jump in blood pressure. And even a small surge in pressure can lead to partial or complete loss of vision. During hypertensive angiopathy, the capillaries of the retinas of both eyes are affected, but with varying degrees of severity, which is determined during an examination by an ophthalmologist.

The first stage of the pathology is asymptomatic; the person has no idea about the development of the pathological process in his eye. Severe symptoms arise only over some time, when gross changes begin to occur in the retina and the eyeball itself, interfering with normal functioning. But at this stage, the patient may notice dark spots flashing before the eyes. When changes begin to occur, the following symptoms appear:

• Pain in the eyes;
• blurriness and splitting of visible objects;
• a decrease in the field of vision, due to which entire areas fall out of it. The phenomenon may be periodic or constant;
• blurred vision;
• light sensitivity is impaired;
• pulsation in the eyeball. Rarely encountered;
• development of myopia;
• yellowish fatty spots in the eyes;
• pain in the lower extremities;
• high blood pressure;
• bleeding from the sinuses.

All the time during the development of hypertensive angiopathy, vision deterioration occurs, which in the end can completely disappear, making the person disabled.

Diagnosis and treatment of hypertensive angiopathy

The duration and success of therapy depends on the timeliness of visiting a doctor and identifying the disease. First of all, the doctor listens to the patient’s complaints and examines the fundus of the eye using ophthalmoscopy. If this procedure is not enough, the following diagnostic examinations may be prescribed:

• radiography;
• ultrasonography;
• retinal angiography;
• ophthalmodynamometry.

These measures make it possible to detect the slightest changes in the structure of the vessels of the retina, as well as evaluate their characteristics, thanks to which the doctor can choose the most appropriate treatment in a particular case. After hypertensive type angiopathy has been detected, the doctor prescribes treatment, which is primarily aimed at treating hypertension. Complex treatment of retinal angiopathy of the hypertensive type consists of the following:

• taking medications that lower blood pressure;
• use of anticoagulants;
• the use of vasodilators that restore blood flow in the retina;
• carrying out procedures of laser coagulation, magnetic therapy and some others;
• prevention of blood clots;
• decreased blood viscosity;
• resorption of hemorrhages;
• use of eye drops;
• taking vitamin and mineral complexes;
• normalization of daily routine;
• balanced diet;
• getting rid of bad habits.

Also, to achieve a better result, the patient will need to get rid of extra pounds, lead an active lifestyle and, of course, try to avoid stressful situations. Timely consultation with a doctor will prevent the development of such serious complications as vision loss. Treatment therapy is selected by an ophthalmologist together with a therapist; self-medication is highly discouraged, otherwise the consequences could be even worse.

Hypertensive retinal macroangiopathy is a complication of chronic high blood pressure. How to recognize and treat this disease?

Chronic increase in blood pressure (BP), or hypertension, leads to vascular pathology throughout the body. As a rule, there is a narrowing of arteries and small capillaries, disruption of microcirculation and blood supply to organs. Such pathological changes in the blood vessels of the eye are called hypertensive retinal angiopathy.

This condition is characterized by persistent and progressive visual impairment and can cause complete blindness if left untreated.

Causes and pathogenesis

The main factor in the development of the disease is a persistent increase in blood pressure.

It is classified according to severity:

• mild - 140–159/90–99 mmHg;
• average - 160–179/100–109 mm Hg. st;
• severe - 180/110 mm Hg. st and above.

Arterial hypertension is a polyetiological disease and can be provoked by:

• exposure to stress and psycho-emotional tension;
• bad habits (smoking, alcohol abuse);
• chronic intoxication, for example, at work, etc.;
• overweight;
• unhealthy diet;
• chronic kidney diseases, endocrine system, etc.

A prolonged increase in pressure leads to disruption of the nervous regulation of vascular tone, compensatory growth of the arterial bed and venous stagnation.

Hypertensive retinal angiopathy is a consequence of these changes and, as a rule, develops after 30–35 years.

Vascular pathology is aggravated by such concomitant conditions as:

• cervical osteochondrosis (there is a decrease in the volume of blood flowing to the upper limbs and head: it occurs due to a narrowing of the artery canal in the spinal column);
• injuries that reduce blood supply to the eyeballs;
• metabolic disorders: diabetes mellitus, metabolic syndrome (cause thickening of the walls of blood vessels and clogging of their lumen);
• blood diseases (due to a violation of the ratio of formed elements and the liquid part of the blood);
• age-related involutive changes.

Clinical picture

Retinal angiopathy of the hypertensive type usually has a slowly progressive course: at first the symptoms are minor and do not cause concern to the patient, but over time the condition worsens.

Angiopathy caused by increased blood pressure is characterized by complaints of:

• decreased clarity of vision: the picture before the eyes becomes cloudy, there is a feeling of a veil before the eyes;
• myopia: the patient sees well near, but distant objects become blurry;
• progressive vision loss, eventually leading to complete blindness;
• the appearance of bright flashes, “lightning” before the eyes, associated with impaired blood supply to the light receptors of the retina;
• the appearance of floating dark spots before the eyes;
• narrowing of the field of view - the patient sees objects located in front of him better, the angle of peripheral vision decreases;
• headaches caused by a decrease in the supply of oxygenated blood to the brain and resulting hypoxia;
• a feeling of pulsation in the eyeballs, which is provoked by increased blood flow through narrowed capillaries;
• nosebleeds due to angiopathy of the nasal vessels and the Kisselbach area, which is close to the surface of the mucosa and bleeds easily;
• pain in the lower extremities, which occurs due to narrowing of the small peripheral vessels of the legs;
• the appearance of blood in the urine caused by damage to the arteries of the kidneys;
• gastrointestinal bleeding.

Upon careful examination of the sclera, you can notice an extensive network of capillaries, yellow spots, and pinpoint hemorrhages.

Diagnostics

To make a diagnosis of hypertensive retinal angiopathy, the ophthalmologist is based on clinical symptoms, as well as instrumental examination methods. Examination of the fundus allows you to determine what stage of angiopathy it is.

1. Functional angiopathy - narrowing of the arteries and dilation of the retinal veins, the appearance of pathologically branched vessels of various sizes.
2. Stage of organic change. The narrowing and tortuosity of the arterioles progresses; they become similar first to thin copper and then to silver wire due to the narrowing of the light space inside the vessel. Some vessels are completely sclerotic and appear on examination as thin white lines. The fundus of the eye is pale, sometimes a waxy tint can be seen. Retinal hemorrhages and thrombosis, vascular microaneurysms occur. New modified vessels sprout in the area of ​​the optic nerve head.
3. Angioretinopathy. The stage of gross changes is manifested by hemorrhage and swelling of the retina, the appearance of bloodless foci of a pale, almost white color. The boundaries of the optic nerve head blur, become unclear, and swelling occurs. Thrombosis in the vessels progresses, they become sclerotic, and the blood supply to the retina of the eye is disrupted.

In addition to examining the fundus of the eye, to clarify the form and course of angiopathy, the following diagnostic tests must be performed:

• general urine and blood tests to determine concomitant pathologies of the kidneys and the body as a whole;
• measuring blood pressure (at least three times in a quiet environment) to determine the degree of hypertension;
• electrocardiography.

Treatment

Hypertensive angiopathy of retinal vessels is not an independent disease, but a complication of chronic arterial hypertension. Therefore, complex therapy for this condition and maintaining blood pressure numbers at the target value (not higher than 140/90 mm Hg) are important:

• normalization of lifestyle, diet, smoking cessation, walking and individually selected physical activity;
• prescribing one or more antihypertensive drugs:
  1. diuretics (diuretics: indapamide, furosemide, veroshpiron) - normalize blood pressure by reducing the volume of circulating blood;
  2. ACE inhibitors (enalapril, lisinopril) - interfere with the regulation of water-salt balance, reduce vascular tone;
  3. beta blockers (propranolol, metoprolol) - reduce peripheral vascular resistance and afterload on the heart;
  4. calcium channel blockers (nifedipine, verapamil) to dilate narrowed blood vessels.
• daily blood pressure monitoring;
• with elevated cholesterol levels, its normalization: a diet with limited animal fats, taking lipid-lowering drugs from the group of statins (atorvostatin, simvastatin), fibrates (clofibrate, simfibrate);
• prescription of drugs that restore microcirculation of the vascular bed of the eyeball (trental, solcoseryl, mildronate, emoxypine);
• symptomatic treatment, vitamin complexes (“Anthocyan Forte”, “Lutein complex”);
• physiotherapy (laser irradiation, magnetic therapy, laser therapy);
• gymnastics for vision.

Patients with hypertensive retinal angiopathy should be registered at a dispensary and regularly (2 times a year) examined by an ophthalmologist, therapist and cardiologist. An integrated approach to treating the disease, maintaining a healthy lifestyle, normalizing blood pressure and taking vascular medications will help stop the progression of angioretinopathy and preserve vision.

Angiopathy is a change in blood vessels, accompanied by a violation of their capacity. Angiopathy can also develop in the vessels of the fundus. Then it qualifies as retinal angiopathy. This is not an independent disease, but a manifestation of certain diseases that affect blood vessels. Retinal angiopathy is manifested by pathological changes in the blood vessels of the fundus. It occurs due to a violation of nervous regulation. Because of this disorder, the inflow and outflow of blood through the vessels is hampered.

Since retinal angiopathy is accompanied by impaired blood supply to the eye and congestion, its consequences are disruption of the functioning of the eye. Treatment should be prescribed as quickly as possible; its effectiveness depends on the degree of retinal angiopathy.

How does retinal angiopathy develop?

Retinal angiopathy can be of several types depending on the cause:

• Diabetic,
• Hypertensive,
• Hypotonic,
• Traumatic.

This vascular damage develops most often after the age of 30, when the underlying disease that causes angiopathy already leads to changes in the vessels located in the fundus. The most common causes of angiopathy are hypertension and diabetes mellitus.

In diabetes, mucopolysaccharides are deposited on the walls of blood vessels, as a result of which the lumen of the blood vessels narrows. Microcirculation disorders lead to hypoxia and lack of nutrition, all of which inevitably affects the functions of the eye.

With hypertension, the veins of the fundus dilate due to their overflow with blood, the venous bed becomes branched, and pinpoint hemorrhages appear on the surface of the eyeball. Further development of angiopathy leads to increased hemorrhages and clouding of the retina. In this case (unlike diabetes mellitus), the changes can be reversible with grade 1 angiopathy. If it is possible to eliminate hypertensive phenomena, then the vessels return to normal.

Degrees of hypertensive retinal angiopathy

With regard to retinal angiopathy that has developed due to hypertension, there is a classification depending on the degree of vascular damage. Determination of the grade is based on an ophthalmological examination of the patient's fundus.

Retinal angiopathy 1st degree - physiological changes:

• The retinal arteries narrow and the veins dilate,
• The caliber of the vessels is uneven,
• The tortuosity of blood vessels increases.

Retinal angiopathy grade 2 - organic changes:

• The unevenness of the caliber of the vessels and their tortuosity increases even more,
• The vessels become similar to light copper wire due to the narrowing of the central light strip along the vessel,
• Further narrowing of the light strip makes the vessels look like silver wire,
• The damage to some vessels is so severe that they are visible in the form of white thin lines,
• Thrombosis of fundus vessels and hemorrhage,
• Microaneurysms and newly formed vessels in the area of ​​the optic nerve head,
• The fundus of the eye is pale, in some patients with a waxy tint.

Retinal angiopathy grade 3 – angioretinopathy:

• Retinal hemorrhages
• retinal edema,
• White spots in the retina
• Blurred boundaries of the optic nerve,
• Papilledema.

Manifestations of retinal angiopathy

At first, the process may be asymptomatic. Some symptoms of retinal angiopathy gradually appear. Patients note the flickering of “floaters” before the eyes, the appearance of dark spots in the field of vision. Vision begins to deteriorate and at the stage of angioretinopathy (grade 3) it may completely disappear. With stage 2 retinal angiopathy, the field of vision may change and light sensitivity may be impaired. Characterized by blurred vision.

If you detect even slight symptoms of decreased vision or any changes in eye function, you should immediately consult a doctor. This will help to start treatment in time, before irreversible changes in the blood vessels occur.

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The mechanism of development of hypertensive retinal angiopathy and its treatment

Retinal angiopathy of the hypertensive type develops as a result of hypertension, which, as is known, is a chronic disease accompanied by increased blood pressure.

To understand the mechanisms of damage to the vessels of the retina, you must first understand the changes occurring in the body in connection with the development of arterial hypertension.

Why does hypertension develop?

The disease can begin at any age, but is more common during periods of hormonal changes and mental stress. Also, atherosclerosis and hypertension have a very close relationship and, as a rule, are inseparable from each other. It is known that hypertension occurs more often in women, and is more severe in men.

People with a large build, prone to obesity, who have a predominant sedentary lifestyle, or who have constant neuro-emotional stress due to work are most predisposed to hypertension.

The main reason for the development of hypertension is a disruption in the functioning of the higher nervous parts of the central nervous system, which is responsible for blood pressure levels. In fact, hypertension is a neurosis of higher vasomotor centers, which are periodically overexcited due to external or internal factors. This condition can persist for a long time, gradually involving the cardiovascular system and other organs in the pathological process.

Due to the predominant activity of the sympathetic nervous system (one of the departments of the autonomic system), adrenaline and norepinephrine are constantly released into the blood, the effects of which are the narrowing of blood vessels. These substances enhance the work of the heart, which automatically leads to an increase in blood pressure and the inclusion of renal regulation of its level - due to renin and angiotensin, which further enhance vascular spasm and trigger the mechanism of endocrine regulation of the tone and diameter of the vascular wall. As a result, pressor hormones are intensively produced, increasing the tone of the muscular wall of blood vessels.

All these mechanisms help maintain hypertension at a high level and lead to changes in all organs, including the retina.

What happens in the vessels

In hypertension, small arteries are primarily affected - arterioles, which have a developed muscular layer. Therefore, the disease can be called arteriolosclerosis. Quite characteristic changes occur in them - gradually, as the disease progresses, the muscle layer of the walls thickens, and a large number of elastic fibers appear in it (hyperelastosis).

The inside of the vessels narrows greatly, the lumen of the vessels decreases, and the passage of blood becomes difficult. In very small arteries and arterioles, rapid progression of the process or frequent changes in blood pressure (sharp jumps) leads to the replacement of muscle fibers in them with hyaline ones, and the walls themselves become saturated with lipids and lose their elasticity. With prolonged hypertension, thrombosis, hemorrhages and microinfarctions develop in the arterioles.

It is worth emphasizing once again that such changes occur throughout the body and in the vessels of the fundus, in particular. The mechanism of development of hypertensive retinal angiopathy is identical to the mechanism described above.

What can an ophthalmologist see?

The fundus picture will differ significantly depending on the stage of hypertension. All changes are divided into two groups:

1. Occurring in the walls of blood vessels;
2. Occurring in the tissues of the retina.

Hypertensive angiopathy of the retinal vessels most often affects both eyes, but the process may not begin simultaneously, but first in one eye, and after some time appear in the other.

The more changes the ophthalmologist observes in the fundus, the more advanced the stage of hypertension and the less favorable the course of the disease.

The arteries are opaque, pale, sharply narrowed, tortuous and double-circuited (vascular reflex). The veins are dark in color, dilated, corkscrew-shaped, some of them change so much that they resemble cysts. The blood flow in the veins is uneven, intermittent due to compression by dense, spasmodic arteries. This phenomenon (the intersection of wide veins with narrow arteries) is called the Salus symptom.

Tight, narrowed arteries are called the copper wire sign, later they change, become paler and are called the silver wire sign. The smallest vessels, the capillaries, also undergo changes, with small pinpoint hemorrhages appearing around them.

Often these changes occur asymmetrically in both eyes - in one there may be a sharp narrowing of the arterioles, while in the other such a strong spasm will not be visible. This phenomenon is quite typical for hypertensive type angiopathy.

For hypertensive angiopathy of the retina of both eyes, the “bull’s horns” symptom is quite characteristic - branching of the retinal arteries at an obtuse angle. This symptom is caused by long-term hypertension and often this division of the arteries leads to thrombosis, sclerosis and even rupture.

Due to the pathological permeability of retinal vessels, foci of exudates rich in fibrin appear. On examination, it looks like pieces of cotton wool in the fundus. Uniting and increasing in size, they take on the shape of a star.

Swelling of the optic disc in combination with foci of “cotton wool” indicates a severe course of hypertension. Usually the swelling is located around the disc and in the direction of the large retinal vessels. If there is a lot of protein in the exudate released from the vessels, then the edematous tissue acquires an opaque, grayish color. Disc swelling can range from barely noticeable to pronounced, even stagnant.

What can a patient complain about?

In the initial stages of angiopathy, patients, as a rule, do not complain; changes may be noticed by an ophthalmologist, but not always.

Somewhat later, when hypertension becomes stable, complaints may appear about:

• Poor vision at dusk;
• Deterioration of lateral vision;
• Incomplete vision of the object, dark spots that make it difficult to see the object;
• Decreased visual acuity.

The degree of changes in the retina during hypertension depends on the stage of development of the disease, its severity, and the form of the disease. The longer hypertension exists, the more pronounced the symptoms of hypertensive retinal angiopathy. Hypertension detected in the early stages can be cured, and fundus changes can regress.

Treatment of hypertensive retinal angiopathy

Treatment of hypertensive retinal angiopathy is primarily aimed at treating the underlying disease, i.e. hypertension.

To improve the condition of the retina, the following is prescribed:

• Vasodilators are vasodilators that act primarily on the vessels of the brain and eye (Cavinton, Xavin, Stugeron);
• To eliminate hypoxia, inhalations with oxygen or carbogen are prescribed;
• To thin the blood and prevent thrombosis, antiplatelet agents are prescribed - acetylsalicylic acid Cardio, Detromb, CardiASK, Klopidex.
• To protect against free radicals - antioxidants - alpha-tocopherol, vitamin C, Veteron, Diquertin;
• Angioprotectors - Doxium;
• For the resorption of hemorrhages - the enzymes Wobenzym and papain.

Only an integrated approach can improve the condition of the retina. Without treatment of the underlying disease, be it hypertension or symptomatic hypertension due to renal pathology, retinal angiopathy will not go away on its own and will only get worse.

Hypertensive angiopathy of the retina, treatment.

For hypertensive retinal angiopathy Various names have been proposed: albuminuric retinitis, arteriosclerotic retinitis, angiospastic retinitis, hypertensive retinopathy, arteriospastic retinitis, hypertensive angioretinoneuropathy, angio- or retin degeneration.

The fundus picture in hypertensive retinal angiopathy is diverse. Individual forms are combined with each other, but changes can be distinguished both from the blood vessels and those changes that occur in the retinal tissue.

The nature of changes in the fundus in itself and in relation to the development of the general hypertensive process served as the basis for various classifications of hypertensive changes in the retina.

Classification of hypertensive retinal angiopathy

In the development of a classification of hypertensive changes in the retina, as well as in the study of this process in general, the works of Soviet authors play an important role. The classification by A. Ya. Vilenkina is valuable in that it compares changes in the retina with the phases of development of hypertension according to the classifications proposed by the most authoritative Soviet therapists - G. F. Lang, V. F. Zelenin, E. M. Tareev and L. I Fogelson. In addition, it takes into account such forms as hypertension with predominant kidney damage, as well as changes in the retina due to atherosclerosis.

A very important question is what diagnostic and prognostic significance do certain retinal changes have in hypertension. So far there is no consensus on this issue.

Pathogenesis of hypertensive retinal angiopathy

To determine the reactivity of the retinal vessels, the pressure in the central retinal artery is measured during the Valsalva experiment; during this experiment, the pressure in the central retinal artery increases significantly and in healthy people returns to normal after 10 minutes, and in patients with hypertension - no earlier than after 30 minutes . The second test, also with the Valsalva experience, consists of observing the duration of vasodilation. The Valsalva experience causes them to expand, but in healthy individuals the vessels return to normal after 2 minutes, and in patients with hypertension - after 5-10 minutes.

The frequency of retinal changes in hypertension depends on the stage of development of the disease, its severity, and the form of the disease.

Thus, N.A. Pletneva found these changes in 17.3%, while on vessels she observed the phenomenon of crossover (of all three degrees) in 50% of cases.

A. Ya. Vilenkina observed a normal bottom in only 5% of patients, and in the first stage of the disease - in 25-30%, in the second - in 3.5%, and in later stages she did not see a picture of a normal bottom. Assessment of the diagnostic and prognostic value of the fundus picture in hypertension can only be correct when taking into account and comparing the fundus picture and the general condition of the patient. The persistence of high blood pressure is very important for assessing changes in blood vessels. The level of pressure in the central retinal artery plays a significant role. If we take 60-63 mm for systolic pressure in the central retinal artery as the average norm, and 42-48 mm for diastolic pressure, then dynamic monitoring of pressure in the central retinal artery can lead to some conclusions: if, with a decrease in general arterial pressure in the retina, the pressure does not decrease, then this indicates a loss of elasticity in the retinal vessels, their sclerotic changes and a known threat of hemorrhage; if the pressure in the retinal vessels is correspondingly lower than the total pressure, then it can be assumed that the condition of the eye vessels is better than that of other peripheral vessels.

The relative value of the diastolic pressure in the retinal vessels is of great importance: if it exceeds 70% of the diastolic blood pressure, then the prognosis is very difficult.

Regarding the reversibility of those changes that take place in the retina during hypertension, it must be said that not all of them can undergo reverse development when the general process improves; it depends mainly on the nature of the hypertension itself. For example, with toxic hypertension in pregnancy, any form of neuroretinopathy, even the most severe, can end successfully with complete restoration of vision. On the contrary, arteriosclerotic changes in blood vessels, combined with some forms of hypertension, are irreversible.

The pathohistological substrate of retinopathy is still not well understood. Transudation of plasma into both the retina and disc tissue undoubtedly occurs. Transudative fluid stratifies elements of different layers of the retina. The accumulation of fluid is so great in some places that cyst-like spaces appear. The accumulation of fluid and fibrin in the inner layers of the retina ophthalmoscopically has the appearance of cotton wool-like foci. The shiny white spots that form a star shape are histologically lipid deposits.

As for vascular changes, the ophthalmoscopically visible narrowing of blood vessels is not confirmed histologically, but the phenomena of arternosclerosis - hyalinosis with secondary lipid deposition, deformation of the vascular walls - do occur. Small round hemorrhages in the retina occur due to changes in the terminal capillaries.

It is interesting to note that the Russian ophthalmologist A.V. Khodin, already in 1879, was the first to express the opinion that diseases of the retinal vessels are the cause of albuminuric retinitis.

Regarding the pathogenesis of hypertensive retinopathy, there is also no definitively established data yet, but it is very likely that hypoxia occurs due to poor blood supply, which leads to increased permeability of capillary walls and the release of plasma and red blood cells into the retinal tissue.

Treatment of hypertensive retinal angiopathy

Treatment for hypertensive angioretinopathy is reduced to general therapy for hypertension. With the improvement of the general process, changes in the retina may also undergo reverse development. However, no direct relationship is observed.