Shadi Awwad, MD

Classification:

Group I: minimal narrowing of the retinal arteries
Group II: narrowing of the retinal arteries in conjunction with regions of focal narrowing and arteriovenous nicking
Group III: abnormalities seen in groups I and II, as well as retinal hemorrhages, hard exudation, and cotton-wool spots
Group IV (i.e., malignant hypertension): abnormalities encountered in groups I through III, as well as swelling of the optic nerve head.

    The changes seen in groups I and II are typically chronic, and those encountered in groups III and IV are seen with more acute rises in blood pressure. DBP>= 110 correlates with group III; DBP>= 130 correlates with group IV.
    In essentially untreated groups, they found the 3-year survival rates to be 70% for group I, 62% for group II, 22% for group III, and 6% for group IV. With the development and use of modern antihypertensive medications, survival rates have improved in all groups.
   Hypertensive choroidopathy frequently accompanies hypertensive retinopathy when the changes of group IV, and sometimes those of group III, are present. In the acute phase, yellow spots are visible at the level of the retinal pigment epithelium. They are known as Elshnig Nodules. They are hyperfluorescent on fluorescein angiography and appear to occur secondary to fibrinoid necrosis within the choriocapillaris, leading to damage to the overlying retinal pigment epithelium. In severe cases, the intense leakage of plasma from these foci contributes to serous retinal detachment . Over a period of weeks, these spots become pigmented or depigmented. When the spots occur in a linear fashion, they are referred to as Siegrist's streaks.
    With adequate systemic treatment, the fundus changes seen in groups III and IV resolve over a period of weeks to months. However, visual recovery may be limited by retinal pigment epithelial disruption in the macula or optic nerve damage. Local ocular treatment has not been beneficial.