Laporan kasus

Myopia Patologi ODS

PEMBIMBING
Dr. Cut Masdalena, M.Ked (Oph, Sp.M
DIS!S!N O"E#
Cut $ah%i Nadhia Putri, S.&ed
'(')*''+(
KEP,NI-$,,N K"INIK I"M! PEN.,KI- M,-,
$!M,# S,KI- !M!M Dr. /,!0I,# BI$E!N
P$OG$,M S-!DI PENDIDIK,N DOK-E$
!NI1E$SI-,S M,"IK!SS,"E#
-,#!N +'*2
Jurnal
#ypertensi3e retinopathy signs as ris& indi4ators o5 4ardio3as4ular
%or6idity and %ortality
PEMBIMBING
Dr. Cut Masdalena, M.Ked (Oph, Sp.M
DIS!S!N O"E#
Cut $ah%i Nadhia Putri, S.&ed
'(')*''+(
KEP,NI-$,,N K"INIK I"M! PEN.,KI- M,-,
$!M,# S,KI- !M!M Dr. /,!0I,# BI$E!N
P$OG$,M S-!DI PENDIDIK,N DOK-E$
!NI1E$SI-,S M,"IK!SS,"E#
-,#!N +'*2
#ypertensi3e retinopathy signs as ris& indi4ators o5 4ardio3as4ular %or6idity and
%ortality
,6stra4t
Hypertensive retinopathy has long been regarded as a risk indicator for systemic morbidity and
mortality. New population-based studies show that hypertensive retinopathy signs are strongly
associated with blood pressure, but inconsistently associated with cholesterol and other risk
factors of atherosclerosis. Mild hypertensive retinopathy signs, such as generalized and focal
retinal arteriolar narrowing and arteriovenous nicking, are weakly associated with systemic
vascular diseases. Moderate hypertensive retinopathy signs, such as isolated microaneurysms,
haemorrhages and cotton-wool spots, are strongly associated with subclinical cerebrovascular
disease and predict incident clinical stroke, congestive heart failure and cardiovascular mortality,
independent of blood pressure and other traditional risk factors. These data support the concept
that an assessment of retinal vascular changes may provide further information for vascular risk
stratification in persons with hypertension.
Introdu4tion
The retinal circulation undergoes a series of pathophysiological changes in response to elevated
blood pressure.

These changes are manifested clinically as a spectrum of signs commonly

referred to as hypertensive retinopathy.
!
Hypertensive retinal vascular signs can be broadly
classified into arteriolar changes "generalized arteriolar narrowing, focal arteriolar narrowing,
arteriovenous nicking and arteriolar wall opacification# and more advanced retinopathy lesions
"microaneurysms, blot and flame-shaped haemorrhages, cotton-wool spots, hard e$udates and
optic disk swelling#. %ith the e$ception of disk swelling, these signs can be detected fairly
fre&uently in adult populations, even in persons without a known history of hypertension.
'
The significance of hypertensive retinopathy signs as risk indicators of systemic morbidity and
mortality has long been recognized since their description in patients with renal and
cerebrovascular disease by Marcus (unn in the late nineteenth century.
),
,
*
+n fact, an assessment
of hypertensive retinopathy signs for risk stratification is supported by international hypertension
management guidelines, including the ,- .oint National /ommittee on 0revention, 1etection,
2valuation, and Treatment of High 3lood 0ressure ".N/# and the 3ritish -ociety of
Hypertension.
4,
,
5
The guidelines emphasize that hypertensive retinopathy, together with left
ventricular hypertrophy and renal impairment, may be considered an indicator of target organ
damage, suggesting that physicians should consider a more aggressive approach in managing
these patients.
5
Classi5i4ation and diagnosis
The traditional classification of hypertensive retinopathy, dating back to 6'6, was based on
work by 7eith et al.
8
9lthough the modern classification system bears their name, the original
paper
8
was not an attempt to classify hypertensive retinopathy signs but to show that severity of
hypertension itself was predictive of mortality. This classification and its modifications typically
consist of four grades of hypertensive retinopathy with increasing severity: grade consists of
;mild< generalized retinal arteriolar narrowing= grade ! consists of ;more severe< generalized
narrowing, focal areas of arteriolar narrowing and arteriovenous "9># nicking= grade ' consists
of grade and ! signs plus the presence of retinal haemorrhages, microaneurysms, hard e$udates
and cotton-wool spots= grade ), which is sometimes referred to as accelerated "malignant#
hypertensive retinopathy, consists of signs in the preceding three grades plus optic disk swelling
and macular oedema. %hereas the ' year survival of persons with grade hypertensive
retinopathy was 5?@, the survival was only 4@ in those with grade ) retinopathy.
8
The maAor
limitation of this classification system is the difficulty in distinguishing early hypertensive
retinopathy severity "i.e. grade from grade !#, and several proposals for a new systems have
been made.
!,',
,
6
9 simple three-grade classification is proposed at the end of this article
+t is important for the physician to be aware that some of these signs, particularly
microaneurysms, haemorrhages and cotton-wool spots, may also be found in other systemic and
ocular conditions "Table #. The presence of hard e$udates, for e$ample, is more typical of
diabetic retinopathy, while unilateral retinal signs may indicate carotid artery disease. >isual loss
is suggestive of retinal vein occlusion, diabetic retinopathy, accelerated hypertension and other
retinal diseases. Thus, in atypical scenarios, appropriate investigations may be necessary to
e$clude these important diseases.
-a6le *
1ifferential diagnoses of isolated retinal haemorrhage, cotton-wool spots and microaneurysms
Epide%iology
Becent population-based studies have provided data on the prevalence of various hypertensive
retinopathy signs in the general population.
?C5
1ata from these studies indicates that
hypertensive retinopathy signs, defined from retinal photographs, are seen in 'C)@ of adult
individuals aged D)? years "Eig. #.
>iew larger version:
/ig. *
0revalence of hypertensive retinopathy: signs and selected population studies.
There are fewer studies of the long-term incidence of new hypertensive retinopathy signs.
?
1ata
from the 3eaver 1am 2ye -tudy, a study of )6!4 adults aged )'C84 years in %isconsin, showed
that the * year incidence of focal arteriolar narrowing, 9> nicking, retinal haemorrhages and
microaneurysms in people without diabetes ranged from 4@ to ?@.
,sso4iations 7ith %or6idity and %ortality
Blood pressure
9n abundance of data from clinical and population-based studies show a strong, graded and
consistent association of hypertensive retinopathy signs with blood pressure "Table !#.
?C',*C5
3oth the presence

and the development of new hypertensive retinopathy signs

?
are strongly
related to elevated blood pressure. +n the 3eaver 1am 2ye -tudy, hypertensive individuals were
*?C5?@ more likely to have retinal haemorrhages and microaneurysms, '?C)?@ more likely to
have focal arteriolar narrowing and 5?C8?@ more likely to have 9> nicking than normotensive
people. +n addition, hypertensive persons whose blood pressure was still elevated despite use of
antihypertensive medications, an indication of ;poorer< control, were more likely to develop
retinopathy than individuals whose blood pressure was controlled with medication.
-ystemic associations of hypertensive retinopathy signs: selected population-based studies
-everal recent population-based studies have used standardized retinal photography methods to
define hypertensive retinopathy signs and computer-based imaging methods to measure retinal
arteriolar diameters from photographs. Fne of these is the 9therosclerosis Bisk in /ommunities
"9B+/# study, a population-based cohort investigation of cardiovascular disease of persons aged
)*C4) years selected from four ,- communities. Betinal photography was added as a component
of the e$amination and graded for the presence and severity of hypertensive retinal
microvascular changes. The 9B+/ study demonstrated that generalized retinal arteriolar
narrowing, indicated by narrower arteriolar diameters determined from photographs, was
strongly associated with elevated blood pressure, a finding now confirmed in five other
populations using similar methods.
8C!!
However, the clinical applicability of these findings is
unclear, as the subtle degree of arteriolar narrowing associated with elevated blood pressure is
difficult to estimate from ophthalmoscopy. Eor e$ample, each ? mmHg increase in mean
arterial blood pressure was associated with a reduction of only 4 Gm "'@# reduction in retinal
arteriolar diameters in one study.
!!
1ata from 9B+/ and other studies provides increasing evidence that the pattern of associations
of blood pressure with specific hypertensive retinopathy signs varies. (eneralized retinal
arteriolar narrowing and 9> nicking appear to be markers of cumulative long-term hypertension
damage, and are independently linked with past blood pressure levels measured *C8 years before
the retinal assessment.
!?,!,
,
!'
+n contrast, focal arteriolar narrowing, retinal haemorrhages,
microaneurysms and cotton-wool spots reflect more transient changes of acute blood pressure
elevation, and are linked only with concurrent blood pressure measured at the time of the retinal
assessment.
!?,
,
!
9n important finding in the 3eaver 1am 2ye -tudy was the observation that the association
between blood pressure and retinal microvascular signs appears to be weaker with age,
!!
possibly
reflecting greater sclerosis of retinal arterioles in older persons.
Atherosclerosis risk factors
+n contrast with its strong association with blood pressure, hypertensive retinopathy signs have
not been consistently linked to either direct measures of atherosclerosis, such as carotid artery
stenosis, or atherosclerosis risk factors, such as hyperlipidaemia "Table !#. +n the 9B+/ study,
while controlling for blood pressure, generalized arteriolar narrowing was associated with carotid
artery pla&ue but not stenosis, 9> nicking was associated with carotid artery stenois but not
pla&ue and focal arteriolar narrowing was not related to either carotid artery measure.
!
+n the Hoorn -tudy in The Netherlands hyperglycaemia and abdominal obesity were
independently related to incidence of retinal haemorrhages, microaneurysms, hard e$udates and
cotton-wool spots in the non-diabetic general population.
!)
+n the 9B+/ study, hypertensive
retinopathy signs were related to larger waist circumference, an indicator of abdominal obesity.
!*
However, not all studies have found associations between hypertensive retinopathy signs and
abdominal obesity or dyslipidaemia.
8
The association of hypertensive retinopathy signs with novel atherosclerosis risk factors has also
been investigated. /ross-sectional associations of retinal arteriolar narrowing and 9> nicking
with biomarkers of inflammation "e.g. white blood cell counts# and endothelial dysfunction "e.g.
von %illebrand factor# have been reported in the 9B+/ study
!
and by other groups.
8
These studies emphasize the fact that typical signs of hypertensive retinopathy may be related to
vascular processes other than blood pressure.
Stroke and cerebrovascular disease
Numerous studies have reported a strong association between various hypertensive retinopathy
signs and both subclinical and clinical cerebrovascular disease
!4C!8
and stroke mortality.
!6
+n the
9B+/ study, individuals with retinal haemorrhages, microaneurysms and cotton-wool spots, as
defined from photographs, were two to four times more likely to develop an incident clinical
stroke within ' years, even when controlling for the effects of blood pressure, cigarette smoking,
lipids and other risk factors.
'?
9mong the participants without stroke or transient ischaemic
attack, hypertensive retinopathy signs were also related to changes in cognitive function, as
defined by standardized neuropsychological tests over a 4 year period,
'
and to cerebral white
matter hyperintensity lesions
'!
and atrophy, as defined from MB+ scans.
''
Fne of the key observations was that the presence of hypertensive retinopathy may offer
additional predictive value of clinical stroke risk in individuals with MB+-defined subclinical
cerebral disease. +n the 9B+/ study, individuals with both MB+-defined white matter lesions and
hypertensive retinopathy were 8 times more likely Hrelative risk "BB# 8.= 6*@ confidence
interval "/+# *.6C**.)I to develop an incident clinical stroke event than those without either
white matter lesions or hypertensive retinopathy.
'!
Coronary heart disease and heart failure
Hypertensive retinopathy signs have been linked with both subclinical and clinical coronary
heart disease and congestive heart failure. Eor e$ample, various hypertensive retinopathy signs
have been associated with ischaemic changes on electrocardiogram,
')
severity of coronary artery
stenosis on angiography
'*
and incident coronary heart disease and myocardial infarction in men
'4
and women.
'5
The 9B+/ study reported that, after controlling for pre-e$isting risk factors, individuals with
retinal haemorrhages, microaneurysms and cotton-wool spots were twice as likely "BB .64=
6*@ /+ .*!C!.*4# to develop congestive heart failure as individuals without retinopathy.
'8
+n
fact, among low-risk individuals "without pre-e$isting heart disease, diabetes or hypertension#,
the presence of hypertensive retinopathy signs predicted a '-fold increased risk of heart failure
events "BB !.65, 6*@ /+ .)6C*.6#. This is compatible with the interpretation that
microvascular damage to the myocardium from hypertension and other systemic processes may
be a contributing factor in the development of heart failure.
Other systemic diseases
9 number of systemic diseases have been associated with different hypertensive retinopathy
signs "Table !#. +n the 9B+/ study, individuals with 9> nicking, retinal haemorrhages,
microaneurysms and cotton-wool spots were more likely to develop renal dysfunction than those
without these signs.
'6
This association was independent of blood pressure, diabetes and other risk
factors, and was also seen in persons without diabetes or hypertension.
1ata from three population-based studies suggest that generalized retinal arteriolar narrowing, a
marker of blood pressure damage, may in fact predict the development of incident
hypertension.
)?C)!
The 9B+/ study showed that normotensive participants who had generalized
arteriolar narrowing were 4?@ more likely to be diagnosed with hypertension within a
subse&uent '-year period than normotensive individuals without arteriolar narrowing "BB .4!=
6*@ /+ .!C!.8#.
)
This association was independent of an individual<s pre-e$isting blood
pressure levels, body mass inde$ and other known hypertension risk factors.
The 9B+/ and 3eaver 1am 2ye -tudies have also shown that generalized retinal arteriolar
narrowing predicts the incidence of type ! diabetes among persons initially free of diabetes,
independent of diabetes risk factors.
)',
,
))
Thus generalized arteriolar narrowing, possibly
reflecting various systemic peripheral arteriolar changes, may be a preclinical marker of overt
hypertension and diabetes.
Cardiovascular mortality
The study by 7eith et al.
8
was amongst the first to show a dose-dependent increase in mortality
with severity of hypertensive retinopathy changes. -ince then, numerous studies conducted in the
6*?s and 64?s have further shown that persons with hypertension and retinopathy signs are at
increased risk of mortality.
'),)*C)5
However, inferences from many older studies are limited
because of the subAective evaluation of hypertensive retinopathy signs, the lack of data on cause-
specific mortality rates and inade&uate control for potential confounders such as blood pressure
and diabetes.
Nonetheless, more recent studies have provided stronger evidence that hypertensive signs are
markers of mortality risk. +n a nested caseCcontrol analysis of the 3eaver 1am 2ye -tudy,
individuals with retinal microaneurysms and retinal haemorrhages were twice as likely to die
from cardiovascular events as those without these signs.
!6
Clini4al appli4ations
1ata from recent studies support the current hypertension guidelines regarding the prognostic
significance of retinopathy signs.
4,
,
5
The information obtained from an assessment of the
retinopathy status appears to be independent of, and &ualitatively different from, that of
measuring blood pressure or serum lipids, as the presence of retinopathy signs indicates
susceptibility and the onset of preclinical systemic vascular disease. +n particular, it seems that
individuals with certain hypertensive retinopathy signs "e.g. retinal haemorrhages,
microaneurysms and cotton-wool spots# should be more closely monitored for cardiovascular
risk, and may benefit from further investigations "e.g. echocardiogram for heart function# if
clinically indicated.
9 three-grade classification system for hypertensive retinopathy is shown in Table ', and a
suggested approach for patients with various hypertensive retinopathy grades is shown in Eigure
!. +t is important to emphasize that the management for patients with hypertension and
cardiovascular disease should continue to follow standard risk prediction approaches "i.e. based
on assessment of age and gender of the patient, blood pressure and lipid levels, cigarette smoking
status etc#.
-a6le 8
/lassification of hypertensive retinopathy
/ig. +
2valuation and management of a patient with hypertensive retinopathy.
The classification in Table ' groups hypertensive retinopathy signs into mild, moderate and
accelerated "malignant#. 0atients with mild hypertensive retinopathy signs "Eigure '9# will
probably re&uire routine care, and blood pressure control should be based on established
guidelines.
4,
,
5
0atients with moderate hypertensive retinopathy signs "retinal haemorrhage,
microaneurysm, cotton-wool spots# "Eig. '3# may benefit from further assessment of vascular
risk "e.g. assessment of cholesterol levels# and, if clinically indicated, appropriate risk reduction
therapy "e.g. cholesterol-lowering agents#. 0atients with accelerated hypertensive retinopathy
"bilateral disk swelling in the presence of moderate hypertensive retinopathy# "Eigure '/#, which
is relatively rare in the general population but may occur in conAunction with severe
hypertension, will continue to need urgent immediate antihypertensive management, including
possible administration of intravenous medication. +n such scenarios, physicians should aim for a
small stepwise control of blood pressure over a few hours, and avoid a sudden reduction in blood
pressure which may lead to stroke.
/ig. 8
"9# Mild hypertensive retinopathy: 9> nicking "black arrow# and focal narrowing "white arrow#.
"3# Moderate hypertensive retinopathy: retinal haemorrhages "black arrows#, 9> nicking "white
arrow# and generalized retinal arteriolar narrowing. "/# 9ccelerated "malignant# retinopathy:
swelling of optic disk, retinal haemorrhages and cotton-wool spots.
There have been several e$perimental studies
)8,
,
)6
and clinical reports
*?C*!
of regression of
hypertensive retinopathy signs with control of blood pressure. %ith ade&uate hypertension
treatment, resolution of hypertensive retinopathy signs may occur over a period of 4 months
*!
to
a year.
*
Thus follow-up of patients for up to a year after diagnosis may be needed.
These studies also provide some evidence that specifically targeting the microcirculation in
hypertensive individuals may further reduce cardiovascular morbidity and mortality.Eor
e$ample, certain antihypertensive agents "e.g. 9/2 inhibitors# have been suggested to have
direct beneficial effects on microvessel structure and function, beyond their primary effect on
lowering blood pressure.
*!
Therefore such agents may have added therapeutic value in preventing
and treating cardiovascular diseases. However, whether these specific therapies may reverse or
reduce retinopathy changes, and whether this will result in reduced cardiovascular risk, is
currently unclear.
Con4lusions
Hypertensive retinopathy signs may differ in their associations with systemic diseases. +solated
retinal haemorrhages, microaneurysms and cotton-wool spots "moderate hypertensive
retinopathy# appear to be associated with risk of subclinical and clinical stroke, other
cerebrovascular outcomes, congestive heart failure and cardiovascular mortality, independent of
traditional risk factors. +n contrast, the systemic associations for generalized retinal arteriolar
narrowing, focal arteriolar narrowing and 9> nicking "mild hypertensive retinopathy# appear to
be weaker and less consistent. 9n assessment of hypertensive retinopathy signs may provide
important information for vascular risk stratification
References
. Wong TY, Mitchell P (2004) Hypertensive retinopathy. N Engl Me! "#$, 2"$0%$&.
!. Tso M, a'pol (M ($)*2) Pathophysiology o+ hypertensive retinopathy. ,phthal'ology,
*), $$"2%4#.
'. Wong TY, -lein ., -lein /E-, Tielsch M, H011ar! (2, Nieto 3 (200$) .etinal
'icrovasc0lar a1nor'alities, an! their relation to hypertension, car!iovasc0lar !iseases
an! 'ortality. 40rv ,phthal'ol, 45, #)%*0.
4. 60nn .M ($*)2) ,phthal'oscopic evi!ence o+ ($) arterial changes associate! 7ith
chronic renal !iseases an! (2) o+ increase! arterial tension. Trans 8' ,phthal'ol 4oc,
$2, $24%#.
#. 60nn .M ($*)*) ,n ophthal'oscopic evi!ence o+ general arterial !isease. Trans
,phthal'ol 4oc 9-, $*, "#5%*$.
5. Willia's /, Po0lter N., /ro7n M, 2avis M, Mc:nnes 6T, Potter 3, 4ever P4, Tho'
4M. /ritish Hypertension 4ociety g0i!elines +or hypertension 'anage'ent 2004 (/H4;
:<)= s0''ary. /'> 2004? "2*= 5"4%40
5. @ho1anian 8<, /aAris 6(, /lacA H.. et al. (200")The 4eventh .eport o+ the oint
National @o''ittee on Prevention, 2etection, Eval0ation, an! Treat'ent o+ High /loo!
Press0re= the N@& .eport. 8M8, 2*)= 2#50%&2.
8. -eith NM, Wagener HP, /arAer NW ($)")) 4o'e !i++erent typs o+ essential
hypertension= their co0rse an! prognosis. 8' Me! 4ci, $)&, ""2%4".
6. 2o!son PM, (ip 6Y, Ea'es 4M, 6i1son M, /eevers 26 ($))5) Hypertensive
retinopathy= a revie7 o+ eBisting classi+ication syste's an! a s0ggestion +or a si'pli+ie!
gra!ing syste'. H0' Hypertens, $0, )"%*.
?. -lein ., -lein /E-, Moss 4E ($))&) The relation o+ syste'ic hypertension to changes in
the retinal vasc0lat0re. The /eaver 2a' Eye 4t0!y. Trans 8' ,phthal'ol 4oc, )#, "2)%
#0.
. -lein ., -lein /E-, Moss 4E, Wang C ($))4) Hypertension an! retinopathy, arteriolar
narro7ing an! arterioveno0s nicAing in a pop0lation. 8rch ,phthal'ol, $$2, )2%*.
$2. -lein ., 4harrett 8., -lein /E- et al. 8re retinal arteriolar a1nor'alities relate! to
atherosclerosisD The 8therosclerosis in @o''0nities 4t0!y. 8rterioscler Thro'1 <asc
/iol, 20, $544%#0.
'. 4harp P4, @hat0rve!i N, Wor'al! . et al. ($))#) Hypertensive retinopathy in 8+ro;
@ari11eans an! E0ropeans. Prevalence an! risA +actor relationships. Hypertension, 2#,
$"22%#.
$4. 4tolA .P, <ingerling ., !e ong PT et al. .etinopathy, gl0cose, an! ins0lin in an el!erly
pop0lation. The .otter!a' 4t0!y. 2ia1etes, 44, $$%$#.
$#. Wang , Mitchell P, (e0ng H, .ochtchina E, Wong TY, -lein . (200") Hypertensive
retinal vessel 7all signs in the general ol!er pop0lation= the /l0e Mo0ntains Eye 4t0!y.
Hypertension, 42, #"4%4$.
4. Wong TY, -lein ., 4harret 8. et al. 200", The prevalence an! risA +actors o+ retinal
'icrovasc0lar a1nor'alities in ol!er people. The @ar!iovasc0lar Health 4t0!y.
,phthal'ology, $$0, 5#*%55.
5. Y0 T, Mitchell P, /erry 6, (i W, Wang ($))*) .etinopathy in ol!er persons 7itho0t
!ia1etes an! its relationship to hypertension. 8rch ,phthal'ol, $$5, *"%).
8. :Ara' M-, !e ong 3, <ingerling . et al. (2004) 8re retinal arteriolar or ven0lar
!ia'eters associate! 7ith 'arAers +or car!iovasc0lar !isor!ersD The .otter!a' 4t0!y.
:nvest ,phthal'ol <is 4ci, 4#, 2$2)%"4.
6. (e0ng H, Wang , .ochtchina E et al. (200") .elationships 1et7een age, 1loo!
press0re an! retinal vessel !ia'eters in an ol!er pop0lation. :nvest ,phthal'ol <is 4ci,
44, 2)00%4.
!?. 4harret 8., H011ar! (2, @ooper (4 et al. ($)))) .etinal arteriolar !ia'eters an!
elevate! 1loo! press0re. The 8therosclerosis .isA in @o''0nities 4t0!y. 8'
Epi!e'iol, $#0, 25"%&0.
!. Wong TY, H011ar! (2, -lein . et al. (2002) .etinal 'icrovasc0lar a1nor'alities an!
1loo! press0re in ol!er people= The @ar!iovasc0lar Health 4t0!y. /r ,phthal'ol, *5,
$00&%$".
!!. Wong TY, -lein ., -lein /E-, Me0er 4M, H011ar! (2 (200") .etinal vessel !ia'eters
an! their associations 7ith age an! 1loo! press0re. :nvest ,phthal'ol <is 4ci, 44, 4544%
#0.
!'. (e0ng H, Wang , .ochtchina E, Wong TY, -lein ., Mitchell P (2004) :'pact o+
c0rrent an! past 1loo! press0re on retinal arteriolar !ia'eter in an ol!er pop0lation.
Hypertens, 22, $#4"%).
!). van (ei!en H8, 2eAAer M, Moll 8@ et al. (200") .isA +actors +or inci!ent retinopathy in
a !ia1etic an! non!ia1etic pop0lation= the Hoorn 4t0!y. 8rch ,phthal'ol, $2$, 24#%#$.
!*. Wong TY, 20ncan //, 6ol!en 4H et al. (2004) 8ssociations 1et7een the 'eta1olic
syn!ro'e an! retinal 'icrovasc0lar signs= the 8therosclerosis .isA in @o''0nities
4t0!y. :nvest ,phthal'ol <is 4ci, 4#, 2)4)%#4.
25. 4vars0!! -, We!el H, 80rell E, Ti11er 6 ($)&*) Hypertensive eye gro0n! changes=
prevalence, relation to 1loo! press0re an! prognostic i'portance. 8cta Me! 4can!,
$)&*? 204= $#)%$5&.
!5. TanaAa H, Hayashi M, 2ate @ et al. ($)*#) Epi!e'iolgic st0!ies o+ stroAe in 4hi1ata, a
apanese provincial c0ty= preli'inary report on risA +actors +or cere1ral in+action.
4troAe, $5, &&"%*0.
!8. NaAaya'a T, 2ate @, YoAoya'a T, YoshiiAe N, Ya'ag0chi M, TanaAa H ($))&) 8 $#.#;
year +ollo7;0p st0!y o+ stroAe in a apanese provincial city. The 4hi1ata 4t0!y. 4troAe,
2*, 4#%#2.
!6. Wong TY, -lein ., Nieto 3 et al. (200") .etinal 'icrovasc0lar a1nor'alities an! ten;
year car!iovasc0lar 'ortality. 8 pop0lation;1ase! case;control st0!y. ,phthal'ology,
$$0, )""%40.
"0. Wong TY, -lein ., @o0per 2 et al. (200$) .etinal 'icrovasc0lar a1nor'alities an!
inci!ent clinical stroAes. The 8therosclerosis .isA in the @o''0nities 4t0!y. (ancet,
2#*, $$"4%40.
'. Wong TY, -lein ., 4harret 8., et al. (2002) .etinal 'icrovasc0lar a1nor'alities an!
cognitive i'pair'ent in 'i!!le;age! persons= the 8therosclerosis .isA in @o''0nities
4t0!y. 4troAe, "", $4*&%)2.
'!. Wong TY, -lein ., 4harret 8. et al. (2002) @ere1ral 7hite 'atter lesion, retinopathy
an! risA o+ clinical stroAe= The 8therosclerosis .isA in the @o''0nities 4t0!y. 8M8,
2**, 5&%&4.
''. Wong TY, Mosley TH, -lein . (200"). .etinal 'icrovasc0lar a1nor'alities an! M.:
signs o+ cere1ral atrophy in healthy, 'i!!le;age! people. Ne0rology, 5$, *05%$$.
"4. /reslin 2, 6i++or! .W, 3air1airn 3: ($)55) Essential hypertension= a t7enty year
+ollo7;0p st0!y. @irc0lation, "", *&%)&.
'*. Michelson E(, Morganroth , Nichols @W, Mac<a0gh H ($)&)) .etinal arteriolar
changes as an in!icator o+ coronary artery !isease. 8rch :ntern Me!, $"), $$")%4$
'4. 20ncan //, Wong TY, Tyroler H8, 2avis @E, 30chs 32 (2002) Hypertensive
retinopathy an! inci!ent coronary heart !isease in high risA 'en. /r ,phthal'ol, *5,
$002%5.
"&. Wong TY, -lein ., 4harret 8. et al. (2002) .etinal arteriolar narro7ing an! inci!ent
coronary heart !isease in 'en an! 7o'en= The 8therosclerosis .isA in the @o''0nities
4t0!y. 8M8, 2*&, $$#"%)"
'8. Wong TY, .osa'on! W, @hang PP et al. (200#) .etinopathy an! risA o+ congestive heart
+ail0re. 8M8, 2)", 5"%).
'6. Wong TY, @oresh , -lein . et al. (2004) .etinal 'icrovasc0lar a1nor'alities an! renal
!ys+0nction in 'i!!le;age! people. 8' 4oc Nephrol, $#, 245)%&5.
)?. 4'ith W, Wang , Wong TY et al. (2004) .etinal arteriolar narro7ing is associate! 7ith
#;year inci!ent severe hypertension. The /l0e Mo0ntains Eye 4t0!y. Hypertension, 44,
442%&.
). Wong TY, -lein ., 4harret 8. et al. (2004) .etinal arteriolar !ia'eters an! risA o+
hypertension. 8nn :ntern Me!, $40, 24*%##.
)!. Wong TY, 4hanAar 8, -lein ., -lein /E-, H011ar! (2 (2004) Prospective cohort st0!y
o+ retinal vessel !ia'eters an! risA o+ hypertension. /M, "2), &)%*2.
4". Wong TY, -lein ., 4harret 8. et al. (2002) .etinal arteriolar narro7ing an! risA o+
!ia1etes in 'i!!le;age! persons. 8M8, 2*&, 2#2*%"".
)). Wong TY, 4hanAar 8, -lein ., -lein /E-, H011ar! (2 (200#) .etinal arteriolar
narro7ing, hypertension an! s01seE0ent risA o+ !ia1etes 'ellit0s. 8rch :ntern Me!, $5#,
$050%#.
4#. /recAenri!ge 8, 2ollery @T, Parry EH ($)&0) Prognosis o+ treate! hypertension.
@hanges in li+e eBpectancy an! ca0ses o+ !eath 1et7een $)#2 an! $)5&. C Me!, $##,
4$$%2).
)4. /reslin 2, 6i++or! .W, 3air1airn 3:, -earns TP ($)55) Prognostic i'portance o+
ophthal'oscopic +in!ings in essential hypertension. 8M8, $)#, ""#%*.
)5. 3rant ., 6roen ($)#0) Prognosis o+ vasc0lar hypertension= 8 nine year +ollo7;0p st0!y
o+ +o0r h0n!re! an! eighteen cases. 8rch :ntern Me!, *#, &2&.
)8. Pal'er .4, (oo+1o0ro7 2, 2oering @. ($)4*) Prognosis in essential hypertension=
eight;year +ollo7;0p st0!y o+ 4"0 patients on conventional 'e!ical treat'ent. N Engl
Me!, 2"), ))0.
)6. Ha'a!a Y, Niisato E, ,tori T et al. ($))#) ,c0lar +0n!0s changes in 'alignant or
precocio0s stroAe;prone spontaneo0sly hypertensive rats a+ter a!'inistration o+
antihypertensive !r0gs. @lin EBp Phar'acol Physiol 40ppl, 22, 4$"2%"
#0. Morishita ., HigaAi , NaAa'0ra 3 et al. ($))2) .egression o+ hypertension;in!0ce!
vasc0lar hypertrophy 1y an 8@E inhi1itor an! calci0' antagonist in the spontaneo0sly
hypertensive rat. /loo! Press 40ppl, ", 4$%&.
#$. /ocA -2 ($)*4) .egression o+ retinal vasc0lar changes 1y antihypertensive therapy.
Hypertension, 5, $#*%52.
*!. 4trachan MW, Mc-night 8 (200#) :'prove'ent in hypertensive retinopathy a+ter
treat'ent o+ hypertension. N Engl Me!, "#2, e$&
#". 2ahlo+ /, 4tenA0la 4, Hansson ( ($))2) Hypertensive retinal vasc0lar changes 1e+ore
an! a+ter treat'ent. /loo! Press, $, "#%44.
-anda9tanda retinopati hipertensi se6agai indi&ator risi&o %or6iditas dan
%ortalitas &ardio3as&ular
abstrak
Betinopati hipertensi telah lama dianggap sebagai indikator risiko morbiditas dan
mortalitas sistemik . -tudi berbasis populasi baru menunAukkan bahwa tanda-tanda
retinopati hipertensi yang berkaitan erat dengan tekanan darah , tapi tidak konsisten
terkait dengan kolesterol dan faktor risiko lain dari aterosklerosis . Tanda-tanda
retinopati hipertensi ringan , seperti umum dan focal arteriol retina penyempitan dan
arteriovenosa nicking , yang lemah terkait dengan penyakit pembuluh darah sistemik.
Tanda-tanda retinopati hipertensi moderat, seperti microaneurysms terisolasi,
perdarahan dan cotton-wool spots, yang berkaitan erat dengan penyakit
serebrovaskular subklinis dan memprediksi langkah klinis keAadian , gagal Aantung
kongestif dan kematian kardiovaskular , independen dari tekanan darah dan faktor
risiko lainnya . 1ata ini mendukung konsep bahwa penilaian terhadap perubahan
vaskular retina dapat memberikan informasi lebih lanAut untuk stratifikasi risiko
vaskular pada orang dengan hipertensi.
-irkulasi retina mengalami serangkaian perubahan patofisiologi dalam
menanggapi tekanan darah. 0erubahan ini diwuAudkan secara klinis sebagai
spektrum tanda-tanda yang biasa disebut sebagai hipertensi retinopathy. tanda-tanda
pembuluh darah retina hipertensi dapat secara luas diklasifikasikan menAadi
perubahan arteriol " umum penyempitan arteriolar , focal penyempitan arteriolar ,
arteriovenous nicking dan arteriol dinding kekeruhan # dan lesi retinopathy lebih
maAu " microaneurysms , noda dan pendarahan berbentuk api , cotton-wool spots ,
eksudat keras dan disk yang optik bengkak # . 1engan pengecualian disk bengkak ,
tanda-tanda ini dapat dideteksi cukup sering pada populasi dewasa , bahkan pada
orang tanpa riwayat diketahui hypertensi.
0entingnya tanda-tanda retinopati hipertensi sebagai indikator risiko morbiditas
dan mortalitas sistemik telah lama dikenal seAak deskripsi mereka pada pasien
dengan penyakit ginAal dan serebrovaskular oleh Marcus (unn pada akhir century.
7e 6. 3ahkan , penilaian tanda-tanda retinopati hipertensi untuk stratifikasi risiko
didukung oleh pedoman manaAemen hipertensi internasional , termasuk 7omite
(abungan 9- Nasional 0encegahan, 1eteksi , 2valuasi , dan 0enanganan Tekanan
1arah Tinggi " .N/ # dan 3ritish -ociety of Hypertension. pedoman menekankan
bahwa retinopati hipertensi , bersama-sama dengan hipertrofi ventrikel kiri dan
gangguan ginAal , dapat dianggap sebagai indikator kerusakan organ target ,
menunAukkan bahwa dokter harus mempertimbangkan pendekatan yang lebih agresif
dalam mengelola pasien.
7lasifikasi dan diagnosis
7lasifikasi tradisional retinopati hipertensi , dating kembali ke 6'6 , didasarkan
pada karya 7eith et al.8 Meskipun sistem klasifikasi modern yang menyandang nama
mereka, paper8 asli tidak upaya untuk mengklasifikasikan tanda-tanda retinopati
hipertensi tetapi untuk menunAukkan bahwa keparahan hipertensi itu sendiri adalah
prediksi kematian . 7lasifikasi ini dan modifikasi yang biasanya terdiri dari empat
kelas retinopati hipertensi dengan meningkatnya keparahan : kelas terdiri dari J
ringan J umum arteriol retina penyempitan = kelas ! terdiri dari J lebih parah J umum
penyempitan , area fokus penyempitan arteriolar dan arteriovenosa " 9> # nicking =
kelas ' terdiri dari kelas dan ! ditambah tanda-tanda adanya pendarahan retina ,
mikroaneurisma , eksudat keras dan cotton-wool spots , kelas ) , yang kadang-
kadang disebut sebagai dipercepat " ganas # retinopati hipertensi , terdiri dari tanda-
tanda di sebelumnya tiga kelas ditambah cakram optik pembengkakan dan edema
makula . -edangkan survival ' tahun orang dengan kelas retinopati hipertensi
adalah 5? @ , kelangsungan hidup hanya 4 @ pada mereka dengan kelas )
retinopathy.
Hal ini penting bagi dokter untuk menyadari bahwa beberapa dari tanda-tanda
ini, khususnya microaneurysms , perdarahan dan cotton-wool spots , Auga dapat
ditemukan dalam kondisi sistemik dan okular lainnya " Tabel # . 7ehadiran eksudat
keras , misalnya , lebih khas retinopati diabetes , sedangkan tanda-tanda retina
unilateral dapat menunAukkan penyakit arteri karotid . 7ehilangan penglihatan adalah
sugestif dari oklusi vena retina , retinopati diabetes , hipertensi dipercepat dan
penyakit retina lainnya . 1engan demikian , dalam skenario atipikal , penyelidikan
yang tepat mungkin diperlukan untuk mengecualikan penyakit penting ini .
1iagnosis banding perdarahan retina terisolasi , cotton-wool spots dan
mikroaneurisma
-tudi berbasis populasi baru-baru ini telah memberikan data prevalensi berbagai
tanda retinopati hipertensi pada umumnya data population.? - 5 dari studi ini
menunAukkan bahwa tanda-tanda retinopati hipertensi , yang didefinisikan dari foto-
foto retina , terlihat dalam '-) @ dari individu dewasa berusia D )? tahun prevalensi
retinopati hipertensi : tanda-tanda dan studi populasi yang dipilih.
9da penelitian lebih sedikit dari keAadian Aangka panAang 1ata retinopati
hipertensi baru signs.? dari 3eaver 1am 2ye -tudy , sebuah studi dari )6!4 orang
dewasa berusia )'-84 tahun di %isconsin , menunAukkan bahwa keAadian * tahun
focal penyempitan arteriolar , 9> nicking , perdarahan retina dan mikroaneurisma
pada orang tanpa diabetes berkisar antara 4 @ sampai ? @.
9sosiasi dengan morbiditas dan mortalitas tekanan darah kumpulan data dari studi
klinis dan berbasis populasi menunAukkan kuat , dinilai dan konsisten asosiasi tanda-
tanda retinopati hipertensi dengan tekanan darah " Tabel ! # .?-',*-5 3aik
presence dan pengembangan retinopati hipertensi baru yang geAala sangat terkait
dengan tekanan darah tinggi . 1alam 3eaver 1am 2ye -tudy , individu hipertensi
adalah *?-5? @ lebih mungkin untuk memiliki pendarahan retina dan
mikroaneurisma , '?-)? @ lebih mungkin untuk memiliki focal penyempitan
arteriolar dan 5?-8? @ lebih mungkin untuk memiliki 9> nicking daripada orang
normotensif . -elain itu, orang-orang yang hipertensi yang tekanan darah masih
tinggi meskipun penggunaan obat antihipertensi , indikasi control J miskin J , lebih
mungkin untuk mengembangkan retinopati daripada individu yang tekanan darah
dikendalikan dengan obat-obatan .
9sosiasi sistemik tanda-tanda retinopati hipertensi : studi berbasis populasi yang
dipilih, 3eberapa studi berbasis populasi baru-baru ini telah menggunakan metode
fotografi retina standar untuk menentukan tanda-tanda retinopati hipertensi dan
metode pencitraan berbasis komputer untuk mengukur diameter arteriol retina dari
foto . -alah satunya adalah 9therosclerosis Bisk in /ommunities " 9B+/ # studi ,
yang berdasarkan populasi kohort investigasi penyakit kardiovaskular dari orang
yang berusia )*-4) tahun yang dipilih dari empat komunitas 9- . Eotografi retinal
ditambahkan sebagai komponen pemeriksaan dan dinilai untuk kehadiran dan tingkat
keparahan hipertensi perubahan mikrovaskuler retina . 0enelitian 9B+/
menunAukkan bahwa umum retina penyempitan arteriolar , ditunAukkan dengan
diameter arteriol sempit ditentukan dari foto-foto , sangat terkait dengan tekanan
darah tinggi , sebuah temuan sekarang dikonfirmasi dalam lima populasi lain dengan
menggunakan seAenis methods.8 - !! Namun , penerapan klinis dari temuan ini
tidak Aelas , seperti tingkat halus penyempitan arteriolar berhubungan dengan tekanan
darah tinggi adalah sulit untuk memperkirakan dari oftalmoskopi . -ebagai contoh,
setiap peningkatan ? mmHg tekanan darah arteri rata-rata dikaitkan dengan
penurunan hanya 4 m " ' @ # pengurangan diameter arteriol retina dalam satu study.
1ata dari 9B+/ dan studi lain memberikan peningkatan bukti bahwa pola asosiasi
tekanan darah dengan tanda-tanda retinopati hipertensi tertentu bervariasi .
(eneralized arteriol retina penyempitan dan 9> nicking tampaknya penanda
kerusakan Aangka panAang hipertensi kumulatif , dan secara independen terkait
dengan tingkat tekanan darah lalu diukur *-8 tahun sebelum assessment.!? retina , !
,-ebaliknya , fokus penyempitan arteriolar , pendarahan retina , dan mikroaneurisma
cotton-wool spots mencerminkan perubahan yang lebih transien peningkatan tekanan
darah akut , dan dihubungkan hanya dengan tekanan darah bersamaan diukur pada
saat assessment. retina
Temuan penting dalam 3eaver 1am 2ye -tudy adalah pengamatan bahwa
hubungan antara tekanan darah dan tanda-tanda mikrovaskuler retina tampaknya
lemah dengan usia , !! mungkin mencerminkan sclerosis lebih besar dari arteriol
retina pada orang tua .
Eaktor risiko 9terosklerosis
3erbeda dengan hubungan yang kuat dengan tekanan darah , tanda-tanda
retinopati hipertensi belum konsisten terkait dengan baik langkah-langkah langsung
aterosklerosis , seperti stenosis arteri karotis , atau faktor risiko aterosklerosis ,
seperti hiperlipidemia " Tabel ! # . 1alam studi 9B+/ , sekaligus mengontrol tekanan
darah , penyempitan arteriolar umum dikaitkan dengan plak arteri karotid tetapi tidak
stenosis , 9> nicking dikaitkan dengan stenois arteri karotis tapi tidak plak dan fokus
penyempitan arteriolar tidak terkait dengan baik measure.! arteri karotid
1alam -tudi Hoorn di 3elanda hiperglikemia dan obesitas perut secara
independen terkait dengan keAadian pendarahan retina , mikroaneurisma , eksudat
keras dan cotton-wool spots di population. umum non - diabetes 1alam studi 9B+/ ,
tanda-tanda retinopati hipertensi terkait dengan lebih besar lingkar pinggang ,
indikator obesitas. Namun, tidak semua studi telah menemukan hubungan antara
tanda-tanda retinopati hipertensi dan obesitas abdominal atau dyslipidaemia.
Hubungan tanda-tanda retinopati hipertensi dengan faktor risiko aterosklerosis
baru Auga telah diteliti . 9sosiasi cross- sectional dari retina penyempitan arteriolar
dan 9> nicking dengan biomarker peradangan " misalnya Aumlah sel darah putih #
dan disfungsi endotel " misalnya faktor von %illebrand # telah dilaporkan dalam
study! 9B+/ dan oleh groups.
-tudi ini menekankan fakta bahwa tanda-tanda khas dari retinopati hipertensi
mungkin berhubungan dengan proses vaskular selain tekanan darah .
-troke dan penyakit serebrovaskular
-eAumlah penelitian telah melaporkan hubungan yang kuat antara berbagai tanda-
tanda retinopati hipertensi dan kedua subklinis dan klinis serebrovaskular disease!4 -
!8 dan stroke mortality.!6 1alam studi 9B+/ , individu dengan pendarahan retina ,
dan mikroaneurisma cotton-wool spots , sebagaimana didefinisikan dari foto , dua
sampai empat kali lebih mungkin untuk mengembangkan stroke klinis insiden dalam
waktu ' tahun , bahkan ketika mengendalikan untuk efek dari tekanan darah ,
merokok , lipid dan factors.'? risiko lain antara peserta tanpa stroke atau transient
ischemic attack , tanda-tanda retinopati hipertensi Auga terkait dengan perubahan
fungsi kognitif , seperti yang didefinisikan oleh tes neuropsikologi standar selama 4
tahun , ' dan cerebral hyperintensity materi putih lesi '! dan atrofi , sebagaimana
didefinisikan dari MB+ scans.
-alah satu pengamatan penting adalah bahwa kehadiran retinopati hipertensi
mungkin menawarkan nilai prediksi tambahan risiko stroke klinis pada individu
dengan MB+ - didefinisikan penyakit otak subklinis . 1alam studi 9B+/ , individu
dengan baik lesi materi putih MB+ - didefinisikan dan retinopati hipertensi adalah 8
kali lebih mungkin H risiko relatif " BB # 8, = selang kepercayaan 6*@ " /+ #, untuk
keAadian stroke yang klinis insiden dibandingkan tanpa baik lesi materi putih atau
retinopathy.hipertensi. 0enyakit Aantung koroner dan gagal Aantung.
Tanda-tanda retinopati hipertensi telah dikaitkan dengan kedua penyakit Aantung
koroner subklinis dan klinis dan gagal Aantung kongestif . -ebagai contoh, berbagai
tanda-tanda retinopati hipertensi telah dikaitkan dengan perubahan iskemik pada
elektrokardiogram , ') keparahan stenosis arteri koroner pada angiography'* dan
insiden penyakit Aantung koroner dan infark miokard pada men'4 dan women.
0enelitian 9B+/ melaporkan bahwa , setelah mengendalikan faktor risiko yang
sudah ada sebelumnya , individu dengan pendarahan retina , dan mikroaneurisma
cotton-wool spots dua kali lebih mungkin " BB ,64 , 6* @ /+ ,*!-!,*4 # untuk
mengembangkan gagal Aantung kongestif sebagai individu tanpa retinopati .'8
3ahkan, di antara individu yang berisiko rendah " tanpa penyakit Aantung yang sudah
ada sebelumnya , diabetes atau hipertensi # , kehadiran tanda-tanda retinopati
hipertensi memprediksi risiko ' kali lipat peningkatan keAadian gagal Aantung " BB
!,65 , 6* @ /+ ,)6-*,6 # . +ni kompatibel dengan interpretasi bahwa kerusakan
mikrovaskuler ke miokardium dari hipertensi dan proses sistemik lainnya dapat
menAadi faktor yang berkontribusi dalam pengembangan gagal Aantung .
0enyakit sistemik lainnya
-eAumlah penyakit sistemik telah dikaitkan dengan tanda-tanda hipertensi
retinopati yang berbeda. 1alam studi 9B+/ , individu dengan nicking 9> ,
pendarahan retina , dan mikroaneurisma cotton-wool spots lebih mungkin untuk
mengembangkan disfungsi ginAal daripada mereka yang tidak ada geAala. 9sosiasi ini
adalah independen dari tekanan darah , diabetes dan faktor risiko lain , dan Auga
terlihat pada orang tanpa diabetes atau hipertensi .
1ata dari tiga studi berbasis populasi menunAukkan bahwa umum penyempitan
arteriol retina , penanda kerusakan tekanan darah , mungkin sebenarnya memprediksi
perkembangan insiden studi hypertension. The 9B+/ menunAukkan bahwa peserta
normotensif yang umum penyempitan arteriolar adalah 4? @ lebih mungkin
didiagnosis dengan hipertensi dalam Aangka waktu ' tahun berikutnya dibandingkan
orang normotensif tanpa penyempitan arteriolar " BB ,4! , 6* @ /+ ,!-!,8 #
asosiasi ini adalah independen dari yang sudah ada tingkat tekanan darah individu
,indeks massa tubuh dan faktor lain yang diketahui hipertensi risiko .
The 9B+/ dan 3eaver 1am 2ye -tudi Auga menunAukkan bahwa umum arteriol
retina penyempitan memprediksi keAadian diabetes tipe ! di antara orang-orang yang
pada awalnya bebas dari diabetes , independen factors. risiko diabetes , 1engan
demikian umumnya penyempitan arteriolar , mungkin mencerminkan berbagai
arteriol perifer sistemik perubahan , dapat menAadi penanda praklinis hipertensi
terbuka dan diabetes mortalitas kardiovaskular.
0enelitian oleh 7eith et al.8 adalah di antara yang pertama untuk menunAukkan
peningkatan mortalitas dengan keparahan perubahan retinopati hipertensi . -eAak itu,
seAumlah studi yang dilakukan pada 6*?-an dan 64?-an telah lebih lanAut
menunAukkan bahwa orang dengan hipertensi dan retinopathy tanda-tanda berada
pada peningkatan risiko mortality.') ,)* - )5 Namun , kesimpulan dari banyak studi
yang lebih tua terbatas karena evaluasi subAektif dari retinopati hipertensi tanda-tanda
, kurangnya data pada tingkat penyebab kematian - spesifik dan kontrol yang tidak
memadai untuk pembaur potensial seperti tekanan darah dan diabetes .
Meskipun demikian , penelitian yang lebih baru telah memberikan bukti kuat
bahwa tanda-tanda hipertensi merupakan penanda risiko kematian . 1alam analisis
kasus-kontrol berumber dari 3eaver 1am 2ye -tudy , individu dengan
microaneurysms retina dan pendarahan retina dua kali lebih mungkin untuk
meninggal akibat keAadian kardiovaskular seperti yang tanpa geAala.
1ata dari studi terbaru mendukung pedoman hipertensi saat ini tentang
pentingnya prognostik retinopati signs. +nformasi yang diperoleh dari penilaian status
retinopathy tampaknya independen , dan secara kualitatif berbeda , yang mengukur
tekanan darah atau serum lipid , sebagai tanda-tanda retinopati menunAukkan
kerentanan dan timbulnya penyakit vaskular sistemik praklinis . -ecara khusus,
tampaknya bahwa individu dengan tanda-tanda retinopati hipertensi tertentu
" misalnya pendarahan retina , dan mikroaneurisma cotton-wool spots # harus
dipantau lebih dekat untuk risiko kardiovaskular , dan dapat mengambil manfaat dari
penyelidikan lebih lanAut " misalnya echocardiogram untuk fungsi Aantung # Aika
terindikasi secara klinis .
-ebuah sistem klasifikasi tiga kelas untuk retinopati hipertensi ditunAukkan pada
Tabel ' , dan pendekatan yang disarankan untuk pasien dengan berbagai kelas
retinopati hipertensi ditunAukkan pada (ambar ! . 9dalah penting untuk menekankan
bahwa manaAemen untuk pasien dengan hipertensi dan penyakit kardiovaskular harus
terus mengikuti pendekatan standar prediksi risiko " yaitu berdasarkan penilaian dari
usia dan Aenis kelamin pasien , tekanan darah dan kadar lipid , rokok status merokok
dll # .
2valuasi dan pengelolaan pasien dengan retinopati hipertensi.
7lasifikasi pada Tabel ' kelompok hipertensif tanda-tanda retinopati menAadi
ringan, sedang dan dipercepat " ganas # . 0asien dengan tanda-tanda retinopati
hipertensi ringan " (ambar '9 # mungkin akan memerlukan perawatan rutin , dan
kontrol tekanan darah harus didasarkan pada didirikan guidelines. 0asien dengan
tanda-tanda retinopati hipertensi sedang " perdarahan retina , microaneurysm ,
cotton-wool spots # " (ambar . '3 # dapat mengambil manfaat dari penilaian lebih
lanAut dari risiko vaskular " misalnya penilaian kadar kolesterol # dan , Aika terindikasi
secara klinis , terapi pengurangan risiko yang sesuai "misalnya agen penurun
kolesterol # . 0asien dengan retinopati hipertensi dipercepat " bilateral disk yang
bengkak di hadapan hipertensi retinopati moderat # " (ambar '/ # , yang relatif
Aarang terAadi di populasi umum tetapi dapat terAadi dalam hubungannya dengan
hipertensi berat , akan terus membutuhkan manaAemen antihipertensi segera
mendesak , termasuk kemungkinan pemberian obat intravena. 1alam skenario seperti
ini , dokter harus bertuAuan untuk kontrol bertahap kecil tekanan darah selama
beberapa Aam , dan menghindari penurunan mendadak tekanan darah yang dapat
menyebabkan stroke.
9da beberapa studies eksperimental dan laporan klinis regresi tanda-tanda
retinopati hipertensi dengan kontrol tekanan darah . 1engan pengobatan hipertensi
yang memadai , resolusi tanda-tanda retinopati hipertensi dapat terAadi selama
periode 4 bulan hingga tahun yang demikian tindak lanAut dari pasien sampai satu
tahun setelah diagnosis mungkin diperlukan.
-tudi ini Auga menyediakan beberapa bukti yang secara khusus menargetkan
mikrosirkulasi pada individu hipertensi dapat mengurangi morbiditas kardiovaskular
dan mortality. contoh , agen antihipertensi tertentu "misalnya inhibitor 9/2 # telah
disarankan untuk memiliki efek menguntungkan langsung pada struktur microvessel
dan fungsi , di luar utama mereka efek pada menurunkan tekanan darah. Fleh karena
agen tersebut mungkin telah menambahkan nilai terapeutik dalam mencegah dan
mengobati penyakit Aantung . Namun, apakah ini terapi khusus dapat membalikkan
atau mengurangi perubahan retinopati , dan apakah ini akan mengakibatkan risiko
kardiovaskular berkurang , saat ini tidak Aelas.
kesimpulan
Tanda-tanda retinopati hipertensi mungkin berbeda dalam asosiasi mereka dengan
penyakit sistemik . 0endarahan retina terisolasi , dan mikroaneurisma cotton-wool
spots " retinopati hipertensi moderat # tampaknya terkait dengan risiko subklinis dan
klinis stroke, hasil serebrovaskular lainnya , gagal Aantung kongestif dan kematian
kardiovaskular , independen dari faktor risiko tradisional . -ebaliknya , asosiasi
sistemik untuk umum penyempitan arteriol retina , focal penyempitan arteriolar dan
9> nicking " retinopati hipertensi ringan# tampaknya lebih rendah konsisten.
0enilaian terhadap tanda-tanda retinopati hipertensi dapat memberikan informasi
penting untuk stratifikasi risiko vaskular.