Original Article
Frequency of Hypertensive Retinopathy, on the basis of Imtiaz’s
Grading System, at Larkana Pakistan
Syed
Imtiaz Ali Shah, Huda Fatima, Azizullah Jalbani, Shujaat Ali Shah, Partab Rai,
Darikta Dargai Shaikh
Pak J Ophthalmol 2018, Vol. 34, No. 4
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See end of article for authors affiliations …..……………………….. Correspondence to: Syed Imtiaz Ali Shah Professor of Ophthalmology Chandka Medical College/SMBB Medical University Larkana. E-mail: syedimtiazalinaqvi@yahoo.com |
Purpose: To determine the frequency of
hypertensive retinopathy on the basis of “Imtiaz's Grading System of Hypertensive Retinopathy”, at Larkana
Pakistan. Study Design: Case series study. Place and Duration of Study: Department
of Ophthalmology and Medical Unit 1 Chandka Medical College Hospital Larkana, Pakistan from January 2016 to January 2018. Material and Methods: This study was conducted from January 2016 to
January 2018 on 288 clinically diagnosed patients of
hypertension by at least two senior consultants simultaneously and selected
in accordance with inclusion and exclusion criteria. A standard proforma was
filled in for every patient. Complete clinical examination including
fundoscopy and blood pressure level was recorded. SPSS version 20 was used
for data entry and analysis. Results: Utilizing Imtiaz's Grading System of Hypertensive
Retinopathy, out of the total 288 patients, 87 (30.21%) had
hypertensive retinopathy. There were 39 (44.83%) male and 48 (55.17%) female
patients. There were 51 (58.62%) patients who had Grade I hypertensive
retinopathy, 19 (21.84%) patients had Grade II hypertensive retinopathy and
17 (19.54%) patients had Grade III hypertensive retinopathy. There were 83.9%
patients presenting with headache, 35.6% complained of blurred vision, 17.2%
patients complained of floaters, 8% had diplopia, 5.7% patients complained of
pain in the eyes and 10.3% patients presented with transient visual loss
(amaurosis fugax). Conclusion: Early
detection and management of hypertension and its systemic complications to
prolong the life span of hypertensive patients, is possible if symptoms are
given importance towards diagnosis of hypertension. Keywords: Hypertensive retinopathy,
Hypertension, Headache, Diplopia. |
Hypertensive retinopathy
not only causes damage to eyesight but its presence is strongly associated with
cardiovascular disease1. The increasing incidence of hypertension in
the global community i.e. at the start of twenty first century more than a
quarter of the world’s population is suffering from hypertension2. Other
vital organs of the body involved include kidneys and central nervous system,
the most common part of the human body being involved in hypertension is retina3.
Normal view of the retinal vessels visible on ophthalmoscopy is formed by the
reflection from the interface between the blood column and vessel wall4.With
persistently raised blood pressure leading to sclerosis and hyalinization of
vessel walls, the appearance of retinal vessels changes first to red-brown (copper
wiring) and then to complete sheathing (silver wiring) and focal areas of
narrowing develop in them due to vascular spasm followed by fibrosis5.
Sclerosis upon sustained hypertension may shorten or elongate the retinal
arterioles which may consequently lead to deflection of the veins at the common
sheath changing the course of the veins (Salus sign)6. The thickened
wall of retinal arteriole in hypertension leads to compression of vein at the
arteriovenous crossing resulting in dilated vein peripheral to crossing,
arteriovenous nicking, known as the Gunn sign4. The rationale of the
study was to introduce a new Grading
System of Hypertensive Retinopathy which describes three grades of
hypertensive retinopathy on the basis of retinal signs of hypertensive
retinopathy and associated systemic symptoms7. This grading system
was chosen for this study on the basis of the fact that it is based on both
signs and symptoms contrary to other available Grading Systems of Hypertensive
Retinopathy which are based on signs only8, 9,10,11,12. The purpose
of this study was to determine the frequency of hypertensive retinopathy
on the basis of “Imtiaz’s Grading
System of Hypertensive Retinopathy” in this part of Pakistan for the first
time.
MATERIAL AND METHODS
A total of 288 diagnosed patients of essential hypertension
(with persistently raised blood pressure over 150/100 mmHg) presenting at the Department of Ophthalmology
and Department of Medicine Unit-1, Chandka Medical College Hospital Larkana Pakistan from January 2016 to January 2018 were
included in the study, after Ethical Approval from Ethical Review Committee of
SMBB Medical University Larkana Pakistan. On duty residents/consultants of Department
of Ophthalmology and Medicine Unit-1, Chandka Medical College Hospital Larkana were provided with standard proforma and
instructed to record the symptomatic hypertensive patients on the basis of
inclusion/exclusion criteria and report to Author No. 1 and 3 as a part of data
collection procedure. Patients below 20
years of age, with diabetes mellitus, with sickle-cell retinopathy, with
retinal vasculitis and with hypertension due to secondary causes like renal
hypertension and adrenal medulla tumors were excluded
from the study. Complete clinical examination was performed on each patient
including blood pressure monitoring, fundoscopy with direct and indirect
ophthalmoscopes and with 90 D lens on slitlamp biomicroscope. A standard
proforma was filled in for every patient; it included family history of
hypertension, fundoscopic evidence of signs of hypertensive retinopathy and
associated symptoms. Presence of Hypertension in first degree relatives was
considered as positive family history. Sample size was calculated by using the
formula n= z2 p (1-p)
e2
Where ‘n’ is the sample size, ‘z’ is the confidence level, ‘p’ is the
population proportion and ‘e’ is the margin of error. Sample size of 288 was
calculated by keeping the confidence level of 95%, margin of error of 5.78 and
assuming the population proportion to be 50%. Data was entered and analyzed in
SPSS version 20 to assert the correlation of symptoms and signs in the relevant
grades of hypertensive retinopathy by calculating the percentages of gender,
hypertensive retinopathy, its various grades and symptoms among the patients
under study.
RESULTS
We evaluated 288
patients of hypertension out of which 87 (30.21%) patients were found to have
hypertensive retinopathy, among these patients 39 (44.83%) were males and 48
(55.17%) were females. Breakup of these patients in grades and presenting
symptoms are shown in Table-1 & 2 and Figures 1. Utilizing Imtiaz's Grading System of Hypertensive
Retinopathy, out of the total 87 patients, 51 (58.62%) had Grade I
hypertensive retinopathy, 19 (21.84%) patients had Grade II hypertensive
retinopathy and 17 (19.54%) patients had Grade III hypertensive retinopathy. The
most common presenting complaint in patients was headache 73 patients (83.9%)
followed by blurred vision in 31 patients (35.6%), floaters in 15 patients
(17.2%), amaurosis fugax in 9 patients (10.3%), diplopia in 7 patients (8%) and
eye pain in 5 patients (5.7%).
Table 1: Distribution of patients in
various grades of retinopathy.
Symptoms |
Grades of Hypertensive Retinopathy |
|||||
Grade I (n=51) |
Grade II (n=19) |
Grade III (n=17) |
Total (n=87) |
|||
|
Blurred vision |
|
11 |
5 |
15 |
31 |
Headache |
|
45 |
15 |
13 |
73 |
|
Diplopia |
|
0 |
4 |
3 |
7 |
|
Floaters |
|
0 |
12 |
3 |
15 |
|
Eye pain |
|
0 |
0 |
5 |
5 |
|
Amaurosis fugax |
|
0 |
0 |
9 |
9 |
Table 2: Gender Distribution.
|
Distribution of Hypertensive
Retinopathy |
||||
Hypertensive Patients without HR |
Hypertensive Patients with HR |
Total |
|||
Gender |
Male |
|
137 |
39 |
176 |
Female |
|
64 |
48 |
112 |
|
Total |
|
201 |
87 |
288 |
HR = Hypertensive Retinopathy
Fig. 1: Distribution of patients in
various grades.
DISCUSSION
Retina is the only part
of the human body where vasculature can be visualized noninvasively. Therefore
state of vessels can be studied easily, adequately and at earliest in systemic
disorders like hypertension and diabetes. Based on Imtiaz’s Grading System of Hypertensive Retinopathy, our study shows that
most of the patients (71.46%) suffering from hypertension became symptomatic in
the first two grades which is expected to coincide with less damage to the
target organs in the body contrary to grade-3 which may reflect advanced target
organ damage13,14. Underestimation of the importance of
classifying hypertensive retinopathy is not justifiable as it not only guides
the management of retinal problems but stays as a marker of vital organ damage.
International Society of
Hypertension and British Hypertension Society consider that Grade-3 and 4 of Keith, Wagener,
Barker Grading coincides with presence of the target organ damage15,16.
Medical specialists have utilized hypertensive retinopathy to
predict the morbidity and even the mortality related to hypertension17
therefore assessment of hypertensive retinopathy has a crucial place in
management of patients with hypertension18, 19. Researchers have
shown favor for development of hypertensive retinopathy classification
comprising of fewer grades like mild, moderate and malignant20to
facilitate easier clinical use. To our knowledge presently only Imtiaz’s Grading System of Hypertensive
Retinopathy7 is based on both signs/ symptoms and fewer
grades (Three grades). Imtiaz’s grading
of Hypertensive Retinopathy describes three grades of hypertensive
retinopathy, Grade 1. Silver wiring
of arterioles with AV nippings and headaches. Grade 2. As Grade 1 with flame shaped hemorrhages, soft exudates
and floaters. Grade 3. As Grade 2
with papilledema and amaurosis fugax. According to our knowledge, there is one
Grading system “Mitchell-Wong
simplification of KWB system” that utilizes fewer grades
(Three grades) but is based only on signs. Although this study is limited and a
large study is required to better explore the prevalence of hypertensive
retinopathy in this part of Pakistan, the present study has opened the gate of
understanding regarding picking up hypertensive retinopathy at relatively early
stage on the basis of symptoms and has pointed out (30.21%) prevalence of
hypertensive retinopathy in hypertensive population in upper parts of Sindh and
adjacent Baluchistan.
CONCLUSION
The observations of our study reveals that most of the patients had mild
to moderate degree of hypertensive retinopathy (in first two grades of Imtiaz’s
Grading System of Hypertensive Retinopathy, 71.46%) at the time of presentation
and they attended the health facility due to symptoms like blurred vision,
headache and floaters. Therefore, relatively early detection and management of
hypertension and its systemic complications to prolong the life span of
hypertensive patients, is possible if symptoms are given importance towards
early detection and diagnosis of hypertension. On the basis of our study, we
recommend that all symptomatic patients with raised blood pressure must undergo
fundoscopy as a routine in all departments, to detect and manage hypertensive
retinopathy and its associated complications either at the same health facility
or by referral to appropriate place.
Author’s affiliation
Prof. Syed Imtiaz Ali Shah
FCPS, Professor, Department of Ophthalmology
Chandka Medical
College/SMBB Medical University Larkana.
Dr. Huda Fatima
Trainee Registrar, Department of Ophthalmology
Chandka Medical
College Larkana.
Dr. Azizullah Jalbani
Professor, Department of Medicine
Chandka Medical
College/SMBB Medical University Larkana.
Dr. Shujaat Ali Shah
Trainee Registrar, Department of Ophthalmology
Chandka Medical
College Larkana.
Dr. Partab Rai
FCPS, Professor, Department of Ophthalmology
Chandka Medical
College/SMBB Medical University Larkana.
Dr. Darikta Dargai Shaikh
Associate Professor, Department of Ophthalmology
Chandka Medical College/SMBB Medical University Larkana.
Role of Authors
Prof. Syed Imtiaz Ali Shah
Conceived and
designed the research, assessed the cases, wrote the paper.
Dr. Huda Fatima
Collected the
data, did the literature search, drafted the manuscript, assisted in writing
the paper.
Dr. Azizullah Jalbani
Involved in data
collection, analyzed the data, revised the manuscript.
Dr. Shujaat Ali Shah
Revised the
original manuscript, reviewed the cases, analyzed the data and assisted in
writing the paper.
Dr. Partab Rai
Revised the
original manuscript, reviewed the cases.
Dr. Darikta Dargai Shaikh
Involved in data collection.
Disclaimer:
None.
Conflict
of Interest: None.
Source
of Funding: None.
REFERENCES
1.
Wong TY, McIntosh R.
Hypertensive retinopathy signs as risk indicators of cardiovascular morbidity
and mortality. Br Med Bull.
2005 Sept. 73-74: 57-70.
2.
Zampagalione B. Pascale C. Marchisio M, et al. Hypertensive urgencies and emergencies; prevalence and clinical
presentation. Hypertension, 1996; 27: 44-147.
3.
Shubhangi
V Dhadke, Vithal N Dhadke, Dhruv S Batra. Clinical Profile of Hypertensive Emergencies in an Intensive Care
Unit. J Assoc Physici Ind. 2017; 65: 18-22.
4.
Spencer WH. An
Atlas and Textbook (CD-ROM). Systemic
diseases with retinal involvement: vascular diseases. Based on: Ophthalmic
Pathology. WB Saunders Co; 1995.
5.
Wang S, Xu L, Jonas JB, Wang YS, Wang YX, You QS, et al. Five-Year Incidence of Retinal Microvascular Abnormalities and
Associations with Arterial Hypertension: The Beijing Eye Study 2001/2006. Ophthalmol. 2012; 119:
2592–9.
6.
Albert D, Jakobiec F, Christlieb RA. Based on: Principles and Practice of Ophthalmology (CD-ROM). Hypertension. WB
Saunders Co; 1993.
7.
Shah
SIA et al. Concise Ophthalmology Text & Atals. 5th ed. Param B (Pvt.) Ltd.
2018: 85-95.
8.
Wong TY, Mitchell P. Hypertensive
retinopathy. N Engl J Med 2004; 351: 2310– 2317.
9.
Scheie HG. Evaluation of
ophthalmoscopic changes of hypertension and arteriolar sclerosis. AMA Arch
Ophthalmol. 1953; 49: 1170– 1238.
10.
Keith NM, Wagener HP,
Barker NW. Some different types of essential hypertension: their course and
prognosis. Am J Med Sci. 1939; 197: 332–343.
11.
Chatterjee S,
Chattopadhyay S, Hop e-Ross M, Lip PL. Hypertension and the
eye: changing perspectives. J Hum Hypertens. 2002; 16: 667–675.
12.
Ferdinand KC, Saunders E. Hypertension-related morbidity and
mortality in African Americans–why we need to do better. J Clin Hypertens.
2006; 8: 21–30.
13.
Noblat AC, Lopes MB, Lopes AA. Race and hypertensive target-organ
damage in patients from an university-affiliated outpatient care referral
clinic in the city of Salvador. Arq Bras Cardiol. 2004; 82: 116–20, 111–5.
14.
Cheung CY, Ikram MK,
Sabanayagam C, Wong TY. Retinal micro-vasculature as a model to study
the manifestations of hypertension. Hypertens. 2012; 60: 1094–103.
15.
Whitworth JA; World Health Organization,
International Society of Hypertension Wrinting Group. 2003 World Health
Organization (WHO)/ International Society of Hypertension (ISH) statement on
management of hypertension. J Hypertens. 2003; 21(1): 1983-92.
16.
Williams B, Poulter NR, Brown
MJ, Davis M, McInnes GT, Potter JF, et al. British Hypertension Society
guidelines for hypertension management 2004 (BHS-IV): summary. BMJ. 2004, 328
(1): 634-40.
17.
Tso MO, Jampol LM.
Pathophysiology of hypertensive retinopathy. Ophthalmology, 1982; 89: 1132-1145.
18.
Mancia G, Fagard R, Narkiewicz K, et al. ESH/ESC Guidelines for the Management of Arterial Hypertension:
the Task Force for the management of arterial hypertension of the European
Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).
J Hypertens. 2013; 31: 1281-357.
19.
Taylor J. 2013
ESH/ESC guidelines for the management of arterial hypertension. Eur Heart J.
2013; 34: 2108-2109.
20.
Downie LE, Hodgson LAB, D’Sylva C, et al. Hypertensive retinopathy: comparing the Keith-Wagener-Barker to
a simplified classification. J Hypertens. 2013; 31: 960-65.