第十节 高血压性视网膜病变
【症状】
通常无症状，但可有视力下降。
【体征】
见图11.10.1。
【主要体征】
视网膜小动脉全部或部分狭窄，几乎均为双眼受累。
【其他体征】
1.慢性高血压 动静脉交叉处改变，视网膜动脉硬化呈铜丝或银丝样，棉绒斑，火焰状出血，视网膜大动脉瘤，视网膜中央或分支动脉阻塞，或视网膜中央或分支静脉阻塞，偶见新生血管。
2、急性高血压（恶性高血压) 星芒状硬性渗出，视网膜水肿，棉绒斑，火焰状出血，视神经乳头水肿，偶见浆液性视网膜脱离、玻璃体积血。局限性脉络膜萎缩(脉络膜梗塞所致Elschnig斑)是急性高血压既往发作的体征。
注：当高血压性视网膜病变仅出现在一眼，而对侧眼临床表现正常，应怀疑该侧存在颈动脉阻塞，造成该眼无高血压性视网膜病变出现。
【鉴别诊断】
1、糖尿病性视网膜病变 出血通常呈斑点状，微血管瘤常见，少见血管变细。参见本章第十二节糖尿病性视网膜病变。
2、胶原血管病 可出现多发性棉绒斑，但高血压的其他特征性眼底改变少见或无。
3、贫血 出血为主，无明显的动脉改变。
4、放射性视网膜病变 眼部或邻近组织如脑、海绵窦、鼻咽部位有放射治疗史。表现类似高血压性视网膜病变。可发生在放射治疗后的任何时问，但最常见于放射治疗后头几年内。
5、视网膜中央静脉阻塞或视网膜分支静脉阻塞 单侧发病，多发性出血，静脉扩张迂曲，无小动脉变细，可以由高血压所致。参见本章第八节视网膜中央静脉阻塞和第九节视网膜分支静脉阻塞。
【病因学】
1.原发性高血压 发病原因不明。
2.继发性高血压 继发于先兆子痫或子痫，嗜铬细胞瘤，肾病，肾上腺疾病或主动脉狭窄。
【检查】
1、病史 有无高血压、糖尿病病史?有无眼附近组织放射治疗史。
2、全面的眼科检查 特别是散瞳查眼底。
3、测血压。
4、建议患者到内科或急症科就诊 病情的紧急程度取决于血压的高低和有无症状。一般说来，舒张压达110~120mmHg，或出现胸痛、呼吸困难、头痛，精神症状或视物不清合并视盘水肿，需立即进行内科检查及治疗。
【治疗】
内科治疗，控制血压。
【随访】
起病初期每隔2~3个月，然后每隔6~12个月复查。
11.10 Hypertensive Retinopathy
Symptoms
Usually asymptomatic, although may have decreased vision.
Signs
(See Figure 11.10.1.)
Critical. Generalized or localized retinal arteriolar narrowing, almost always bilateral.
Other
Chronic hypertension: Arteriovenous crossing changes, retinal arteriolar sclerosis (“copper” or “silver” wiring), cotton–wool spots, flame-shaped hemorrhages, arterial macroaneurysms, central or branch occlusion of an artery or vein. Rarely, neovascular complications can develop.
Acute (“malignant”) hypertension: Hard exudates often in a “macular star” configuration, retinal edema, cotton–wool spots, flame-shaped hemorrhages, optic nerve head edema. Rarely serous RD or vitreous hemorrhage. Areas of focal chorioretinal atrophy (Elschnig spots of choroidal infarcts) are a sign of past episodes of acute hypertension.
Note
When unilateral, suspect carotid artery obstruction on the side of the normal-appearing eye, sparing the retina from the effects of the hypertension.
Differential Diagnosis
Diabetic retinopathy: Hemorrhages are usually dot-blot, microaneurysms are common, vessel attenuation is less common. See 11.12, Diabetic Retinopathy.
Collagen–vascular disease: May show multiple cotton–wool spots, but few to no other fundus findings characteristic of hypertension.
Anemia: Mainly hemorrhage without marked arterial changes.
Radiation retinopathy: History of irradiation. Most commonly occurs within a few years, but can develop at any time.
CRVO or BRVO: Unilateral, multiple hemorrhages, venous dilation and tortuosity, no arteriolar narrowing. May be the result of hypertension. See 11.8, Central Retinal Vein Occlusion or 11.9, Branch Retinal Vein Occlusion.
Etiology
Primary hypertension: No known underlying cause.
Secondary hypertension: Typically the result of preeclampsia/eclampsia, pheochromocytoma, kidney disease, adrenal disease, or coarctation of the aorta.
Work-Up
History: Known hypertension, diabetes, or adnexal radiation?
Complete ocular examination, particularly dilated fundus examination.
Check blood pressure.
Refer patient to a medical internist or an emergency department. The urgency depends on the blood pressure reading and whether the patient is symptomatic. As a general rule, a diastolic blood pressure of 110 to 120 mm Hg or the presence of chest pain, difficulty breathing, headache, change in mental status, or blurred vision with optic disc swelling requires immediate medical attention.
Treatment
Control the hypertension, as per the internist.
Follow-Up
Every 2 to 3 months at first, and then every 6 to 12 months.
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