Usually, the early grades of hypertensive retinopathy go undetected. A patient may have no significant signs or symptoms to report nor any apparent reason to seek medical attention.

However, as his diastolic blood pressure remains elevated in grades III and IV, retinal lesions may produce blurred vision and scotomata (blind gaps in his visual field). Papilledema or hemorrhage in the macula can result in blindness.

Diagnostic Tests

A physician uses an ophthalmoscopic examination to diagnose hypertensive retinopathy. This examination is used to detect constricted retinal vessels in grades I and II retinopathy and to detect hemorrhages, yellow exudates, and papilledema in grades III and IV retinopathy.

If the patient has papilledema, the ophthalmo­scopic examination will reveal engorged, tortuous retinal veins, flame-shaped retinal hemorrhages in the superficial nerve fiber layer, and round hemorrhages in the deeper nerve layers.

If your patient has hypertensive retinopathy, a physician may prescribe an antihypertensive drug to regulate his diastolic blood pressure-typically, a beta-blocker or diuretic. If other drugs or disorders contraindicate these antihypertensive drugs. the physician will prescribe another one, such as an ACE inhibitor. Controlling the patient’s blood pressure may reduce or eliminate the signs and symptoms of retinopathy. However, if he has experienced optic nerve ischemia, he may have a permanent loss of vision.

Complementary Therapies

Stress reduction and management help reduce blood pressure. Therefore, you should urge your patient to identify the stressors in his life and help him develop and implement methods to cope with them.

Relaxation techniques-exercises that reduce stress by decreasing sympathetic nervous system activity-can reduce blood pressure. In combination with drug therapy, these techniques have even been effectively used for patients with severe hypertension. Relaxation techniques include yoga, meditation, physical relaxation, and physical exercise.

Psychotherapy has also been used successfully as a method of lowering blood pressure. It helps patients deal with anxiety and constructively handle hostile and aggressive impulses. Counseling can also help increase patient compliance with the prescribed drug regimen.

Another therapy, biofeedback, uses specialized equipment to give the patient feedback about his bodily processes. The patient learns to achieve relaxation by self-regulating the autonomic nervous system. Biofeedback can decrease blood pressure; however, the long-term effects of biofeed­back and its success in controlling hypertension aren’t known.

Hypertensive retinopathy results from chronic primary hypertension, malignant hypertension, or eclampsia. If untreated, it can lead to retinal detachment. Plus, retinal vessel damage suggests that the patient has suffered damage to other organs, as well.

Pathophysiology

With retinopathy, retinal changes are categorized according to the severity of the vessel damage. Retinal arteriolar narrowing and increased dias­tolic blood pressure are directly related.

Grade I retinal changes may occur when a patient has mildly elevated diastolic blood pressure, about 90 mm Hg. These retinal changes include vascular spasm and arteriolar constriction.

Grade II retinal changes occur when a patient has sustained elevated diastolic blood pressure of more than 100 mm Hg. These retinal changes include localized and generalized arteriole nar­rowing at arteriovenous junctions.

If the patient’s hypertension is left untreated and his diastolic blood pressure remains above 100 mm Hg, he may experience grade III retinal changes. Occlusion of the retinal arterioles may cause superficial, flame-shaped hemorrhages and small, white areas of retinal ischemia called soft exudate or cotton wool spots. Hard, yellow ­white exudate may produce a star-shaped figure around the macula.

Further untreated hypertension can lead to grade IV retinal changes. The occluded arterioles cause the optic disk to become congested and edematous, leading to papilledema (swelling of the optic nerve head). Papilledema causes the optic disc margins to become blurred and indistinct. Without treatment, this condition can lead to blindness.

Instruct your patient in lifestyle modifications to manage his hypertension. Help him develop a diet plan to reduce his sodium intake and reduce his weight. Also, help him develop an exercise program.If the physician has prescribed an antihypertensive drug, teach your patient the name of the drug, its dosage, and its therapeutic and adverse effects. Explain the relationship between untreated hypertension and chronic complications, such as retinopathy.

Tell the patient that he’ll need regular ophthalmic examinations to detect and monitor retinal changes. Teach him the signs and symptoms of retinal detachment, such as dark irregular floaters, flashes of light, blurred vision, and a progressively enlarged dark area in his field of vision. Tell him to report any of these signs and symptoms to the physician immediately.

If your patient can’t care for himself because of vision limitations, he may require evaluation for home care assistance. If necessary, refer him to an occupational or physical therapist for suggestions on assistive devices and ways he can adapt his home to meet his needs.

Some More Facts

Focus on controlling your patient’s blood pressure. Administer an antihypertensive drug, as ordered. Also, instruct your patient in lifestyle modifications that can help control his hypertension, including limiting his sodium intake, losing weight, and exercising.

If your patient with hypertensive retinopathy is a pregnant woman, monitor her for signs and symptoms of eclampsia and worsening hypertension, which can cause retinal detachment from fluid leaking under the retina. Administer an antihypertensive drug, as ordered. When her hypertension is controlled, the retinal detachment may resolve.

Teach your patient about the various therapies that can work in conjunction with drug therapy and lifestyle modifications. If necessary, refer him to local community agencies for classes taught by qualified instructors. And advise him that patient participation in stress-reducing activities is an important adjunct to medical treatment.