Ophthalmic considerations Retinal vascular complications (hypertensive retinopathy, retinal vein occlusions, retinal arterial occlusions), glaucoma, ischemic optic neuropathy, microvascular cranial nerve palsies, and stroke-related disorders of the afferent and efferent pathways of the visual system are commonly associated with hypertension. Moreover, ophthalmic surgery patients with poorly controlled hypertension may be more susceptible to intraoperative and postoperative complications.

There is strong evidence that certain signs of hypertensive retinopathy, independent of other risk factors, are associated with increased cardiovascular risk. Based on these reported associations, a simplified classification of hypertensive retinopathy was proposed in 2004 (Table 3-6).

In addition to the kidney, the renin angiotensin system (RAS) exists in ocular tissues and are overexpressed in the retina of individuals with diabetes. In the retina, angiotensin II activates receptors that stimulate pathways involved in diabetic retinopathy, such as inflammation, oxidative stress, cell proliferation, pericyte migration, remodeling of extracellular matrix, angiogenesis, and fibrosis. RAS blockade is thought to attenuate or inhibit these pathogenic effects.

The 2017 ACC/AHA guidelines emphasize the importance of patient assessment and education, echoing earlier reviews from the JNC 7 and several other societies (European Society of Hypertension, European Society of Cardiology, American Society of Hypertension, International Society of Hypertension). These organizations generally agree that control of hypertension is possible only if patients are motivated to take their prescribed medications and to maintain healthful lifestyle habits. Motivation improves when individuals develop empathy with and trust in their physicians. As members of the health care team, ophthalmologists have an important role in the identification, monitoring, and shared management of patients with hypertension.

Table 3-6 Classification of Hypertensive Retinopathy With Systemic Associations

• Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004;351(22):2310–2317.