Retinopatía diabética / HTA.  Retinografía de una paciente de 42 años que presenta un Síndrome Metabólico de algunos años de evolución y mal control de los parámetros analíticos.  Este paciente no ha presentado ninguna entidad clínica asociada a sus factores de riesgo, y al realizar la retinografía se observaron alteraciones vasculares (relación AV alterada y cruces), así como del parénquima (exudados blandos con incipipente exudación lipídica perimacular y hemorragias).  En este caso, la retinografía ha puesto de manifiesto la situación de deterioro vascular del paciente, oculta hasta la fecha.

Retinopatía HTA grado III.  Relación AV disminuida con cruces patológicos y afectación parenquimatosa (hemorragias) en la retina más temporal.  Además, podemos apreciar zona de atrofia peripapilar propia del miope.

Artefacto.  Gran destello luminoso central en una retinografía en la que además se puede distinguir una zona de atrofia peripapilar, en relación con una papila miope.

Drusas.  En esta imágen se pueden apreciar acúmulos de material hialino en capas profundas de la retina de forma dispersa.  Por otro lado, son visibles cambios vasculares, como una relación AV disminuida y signos de cruce patológicos. 

BAEZA DÍAZ M1, GIL GUILLÉN V, OROZCO BELTRÁN D, PEDRERA CARBONELL V, RIBERA MONTES C, PÉREZ PONS I, MARTÍNEZ-TOLDOS J

ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGIA

N.º 9 - Septiembre 2004

Objetivo: Analizar la validez de la cámara no midriática para detectar retinopatía diabética y los grados de severidad susceptibles de derivación al oftalmólogo. Analizar los indicadores de gravedad de la retinopatía diabética que puedan ayudar a aumentar la sensibilidad del cribado: Tiempo de evolución de la diabetes prolongado (mayor de 20 años). Mal control metabólico (HbA₁C > 10%).

Método:Se diseñó un estudio observacional transversal para determinar la validez de una prueba diagnóstica (Retinógrafo no midriático Topcon modelo TRC-NW6S). Se utilizaron como criterio de evaluación los indicadores de validez, los valores predictivos, los indicadores de utilidad clínica, y la concordancia. El ámbito del estudio fue atención primaria, se excluyeron los pacientes que tenían catarata severa. El tamaño muestral fue 376 ojos de 188 pacientes diabéticos tipo 2.

Resultados:Se encontró que el 41,25% de los ojos tenían un grado variable de retinopatía diabética y se detectó retinopatía derivable en el 14,3%. Los indicadores de validez analizados mejoraron al aumentar el número de campos retinográficos estudiados, obteniendo unos niveles de sensibilidad mayores del 75%, especificidad mayor del 95%, valores predictivos + mayores del 90% y la concordancia llega a la categoría sustancial o casi perfecta cuando utilizamos dos o tres campos retinográficos.

Conclusiones: El análisis de las fotografías de fondo de ojo en formato digital se puede considerar un método válido con respecto al método de certeza y los indicadores de gravedad analizados pueden jugar un papel orientador al obtener mayores prevalencias de retinopatía diabética derivable, pero no pueden ser utilizados como prueba aislada para tomar decisiones clínicas.

Kwon HM, Kim BJ, Oh JY, Kim SJ, Lee SH, Oh BH, Yoon BW.

Department of Neurology, Kyunghee University East-West Neo Medical Center, Seoul, Republic of Korea. 

BACKGROUND AND PURPOSE: Silent brain infarction (SBI), which is cerebral target organ damage of hypertensive microangiopathies, is frequently seen in hypertensive patients. The purpose of this study is to investigate the relation between hypertensive retinopathy (HTR) and SBI in subjects without a history of stroke or transient ischemic attack. METHODS: Five hundred-fifty hypertensive subjects without history of stroke or transient ischemic attack had brain MRI and retinal photographs taken. The presence of SBI was assessed from the MRI scans, which was defined as a lesion of at least 3 mm in diameter with typical imaging characteristics. The presence HTR was defined from digitized retinal photographs. RESULTS: Seventy-seven subjects (14%) showed HTR (grade 1 in 46, grade 2 in 31 persons). A multivariate analysis showed that age (OR, 1.07; 95% CI, 1.03 to 1.10) and HTR (OR, 2.01 for grade 1; OR, 3.03 for grade 2) were the independent indicators for the presence of SBI. The higher the grade of HTR, the more prevalent SBI than persons with normal retina (by linear by linear association test, p=0.001). CONCLUSION: HTR is associated with the presence of SBI. This finding suggests that retinal photography may be useful for identifying hypertensive subjects at increased risk of having SBI regardless of current blood pressure status.

J Neurol Sci. 2007 Jan 31;252(2):159-62. Epub 2006 Dec 19

Cooper LS, Wong TY, Klein R, Sharrett AR, Bryan RN, Hubbard LD, Couper DJ, Heiss G, Sorlie PD.

National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.

Stroke. 2006 Jan;37(1):82-6. Epub 2005 Nov 23

BACKGROUND AND PURPOSE: Retinal microvascular abnormalities reflect cumulative small vessel damage from elevated blood pressure and may reflect subclinical cerebral microvascular changes. We examined their associations with MRI-defined cerebral infarcts. METHODS: Population-based, cross-sectional study of 1684 persons 55 to 74 years of age without a history of clinical stroke, sampled from 2 US southeastern communities. Retinal photographs were obtained and graded for presence of retinal microvascular abnormalities, including arteriovenous nicking, focal arteriolar narrowing, retinal hemorrhages, soft exudates and microaneurysms. Photographs were also digitized, and retinal vessel diameters were measured and summarized as the arteriole-to-venule ratio (AVR). Cerebral MRI scans were graded for presence of cerebral infarct, defined as a lesion > or =3 mm diameter in a vascular distribution with typical imaging characteristics. RESULTS: There were a total of 183 MRI cerebral infarcts. After adjustment for age, gender, race, 6-year mean arterial blood pressure, diabetes, and other stroke risk factors, cerebral infarcts were associated with retinal microvascular abnormalities, with odds ratios 1.90 (95% CI, 1.25 to 2.88) for arteriovenous nicking, 1.89 (95% CI, 1.22 to 2.92) for focal arteriolar narrowing, 2.95 (95% CI, 1.30 to 6.71) for blot hemorrhages, 2.08 (95% CI, 0.69, 6.31) for soft exudates, 3.17 (95% CI, 1.05 to 9.64) for microaneurysms, and 1.74 (95% CI, 0.95 to 3.21) for smallest compared with largest AVR. In stratified analyses, these associations were only present in persons with hypertension. CONCLUSIONS: Retinal microvascular abnormalities are associated with MRI-defined subclinical cerebral infarcts independent of stroke risk factors. These data suggest that retinal photography may be useful for studying subclinical cerebrovascular disease in population-based studies.

Tien Yin Wong, MD, PhD; Anoop Shankar, MD, MPH; Ronald Klein, MD, MPH; Barbara E. K. Klein, MD, MPH; Larry D. Hubbard, MAT

Arch Intern Med. 2005;165:1060-1065.

Background  Microvascular disease and hypertension have been linked with risk of diabetes mellitus. We examined the association of retinal arteriolar narrowing, a marker of chronic hypertension, with incident diabetes.

Methods  Prospective cohort study of 3251 nondiabetic persons aged 43 to 86 years living in Wisconsin. The diameters of retinal vessels were measured from baseline retinal photographs of participants. Retinal measurements were summarized as the retinal arteriole-to-venule ratio, with smaller ratios indicating narrower arteriolar diameters. Incident diabetes cases were ascertained at the 5-year and 10-year follow-up examinations.

Results  There were 249 incident diabetes cases. Participants with narrower retinal arteriolar diameters had a higher incidence of diabetes (cumulative incidences of 5.1%, 7.0%, 9.2%, and 11.7%, comparing decreasing quartiles of arteriole-to-venule ratio). After controlling for baseline casual blood glucose level, glycosylated hemoglobin level, body mass index, and other risk factors, retinal arteriolar narrowing was significantly associated with risk of incident diabetes (multivariable-adjusted relative risk, 1.53; 95% confidence interval, 1.03-2.27; comparing smallest to largest arteriole-to-venule ratio quartiles). Participants with both hypertension and retinal arteriolar narrowing had a 3-fold higher risk of incident diabetes (multivariable-adjusted relative risk, 3.41; 95% confidence interval, 1.66-6.98) than normotensive participants without arteriolar narrowing.

Conclusions  Retinal arteriolar narrowing is related to risk of incident diabetes. These data suggest a possible link between systemic arteriolar narrowing associated with hypertension and diabetes development.

Hubbard LD, Brothers RJ, King WN, Clegg LX, Klein R, Cooper LS, Sharrett AR, Davis MD, Cai J
Ophthalmology Dec 1999; 106(12) :2269-80

Affiliation
ARIC Retinal Reading Center, Department of Ophthalmology & Visual Sciences, University of Wisconsin-Madison, 53705-2397, USA.

OBJECTIVE: To develop protocols to photograph and evaluate retinal vascular abnormalities in the Atherosclerosis Risk in Communities (ARIC) Study; to test reproducibility of the grading system; and to explore the relationship of these microvascular changes with blood pressure. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: Among 4 examination centers, 11,114 participants (48-73 years of age) at their third triennial examination, after excluding persons with diabetes from this analysis. METHODS: One eye of each participant was photographed by technicians with nonmydriatic fundus cameras. Reading center graders evaluated focal arteriolar narrowing, arteriovenous (AV) nicking, and retinopathy by examining slides on a light box and measured diameters of all vessels in a zone surrounding the optic disc on enhanced digitized images. To gauge generalized narrowing, vessel diameters were combined into central arteriolar and venular equivalents with formulas adjusting for branching, and the ratio of equivalents (A/V ratio) was calculated. MAIN OUTCOME MEASURES: Retinal vascular abnormalities, mean arteriolar blood pressure (MABP). RESULTS: Among 11,114 participants, photographs were obtained of 99%, with quality sufficient to perform retinal evaluations in 81%. In the 9040 subjects with usable photographs, A/V ratio (lower values indicate generalized arteriolar narrowing) ranged from 0.57 to 1.22 (median = 0.84, interquartile range = 0.10), focal arteriolar narrowing was found in 7%, AV nicking in 6%, and retinopathy in 4%. Because of attrition of subjects and limitation of methods, prevalence of abnormality was likely underestimated. Controlling for gender, race, age, and smoking status, these retinal changes were associated with higher blood pressure. For every 10-mmHg increase in MABP, A/V ratio decreased by 0.02 unit (P < 0.0001), focal arteriolar narrowing had an odds ratio (OR) of 2.00 (95% confidence interval [CI] = 1.87-2.14), AV nicking had an OR of 1.25 (95% CI = 1.16-1.34), and retinopathy had an OR of 1.25 (95% CI = 1.15-1.37). For any degree of generalized narrowing, individuals with focal narrowing had MABP approximately 8 mmHg higher than those without (P < 0.0001). Masked replicate assessment of a sample found the following reproducibility: for A/V ratio, correlation coefficient = 0.79 and median absolute difference = 0.03; for focal arteriolar narrowing, kappa = 0.45; for AV nicking, kappa = 0.61; and for retinopathy, kappa = 0.89.

CONCLUSION: Protocols have been developed for nonmydriatic fundus photography and for evaluation of retinal vascular abnormalities. Several microvascular changes were significantly associated with higher blood pressure; follow-up will show whether these are predictive of later cerebrovascular or cardiovascular disease independently of other known risk factors.

 

Retinopatía diabética.  Microaneurismas / microhemorragias, exudados duros y alguno blando, que se extienden por toda la retina.  Conviene reparar en la excavación papilar, que impresiona de aumentada de tamaño.

Retinopatía HTA grado III.  Esta retinografía del OD de un hipertenso de edad, muestra interesantes hallazgos: *Relación AV claramente disminuida, *Pequeña hemorragia en llama cercana a la papila, *Exudado blando que envuelve a la arteriola temporal inferior, *Algunas drusas por encima de la mácula, y *Destello luminoso inferior (artefacto).

Hemovítreo. La transparencia de los medios es fundamental para la obtención de una imagen de calidad de la retina, circunstancia que puede ocurrir con frecuencia en el caso de las cataratas, o como en este paciente, en el que se aprecia un velamiento difuso por contenido sanguinolento en el vítreo.  La hemorragia vítrea puede estar ocasionada por sangrado expontáneo de los neovasos (retinopatía diabética proliferativa), rotura de aneurismas, desprendimientos de retina, procesos expansivos y traumatismos. Como factor de riesgo podemos destacar el trratamiento anticoagulante.  Los pacientes notan opacidades o cuerpos flotantes que aparecen de forma expontánea en función de la gravedad de la hemorragia.  Una gran cantidad de casos se reabsorben sin tratamiento.

Retinopatía diabética fotocoagulada.  La maculopatía diabética constituye una situación de gravedad en la evolución de la retinopatía diabética, tal es el caso de esta retinografía, en la que se realizó panfotocoagulación, en un intento de evitar la exudación lipídica / edema macular.

Fondo miope.  Se trata de una visión nasal del O.D. de un individuo de edad (aspecto atigrado del fondo), en el que destaca una papila ovalada con zona de atrofia retiniana anexa.  Son apreciables por transparencia, vasos de la coroides a nivel de los campos nasales, debido al adelgazamiento de la retina, características habituales de los fondos miopes.

Agujero macular.  Se trata de una pérdida del tejido retiniano a nivel de la fóvea, que puede estar asociado a traumatismos, miopía elevada, procesos inflamatorios, o bien idiopáticos. En casos avanzados, se caracterizan por la presencia de un defecto mayor a 400 micras asociado a una separación completa de la hialoides posterior de la retina, pérdida de agudeza visual y escotoma central.

Retinopatía diabética proliferativa.   Pueden apreciarse incipientes neovasos en la papila, junto con exudación lipídica perimacular.  A nivel de los vasos destacan una relación AV disminuida junto con cruces patológicos (HTA).

Retinopatía HTA grado II.  Se presenta en detalle ampliado vasos con una relación AV disminuida, refuerzo de la pared de la arteriola (hilo de cobre) y cruce AV.

Nevus.  En esta retinografía podemos apreciar un nevus localizado en arcada temporal sup. sobre el que parecen distinguirse varias drusas.  Por otro lado, son destacables destellos luminosos en campos sup. e inf. (artefactos).