The correct answer is C. The changes illustrated are those of hypertensive retinopathy, and may additionally include yellow hard exudates (caused by lipid deposition in the retina) and a congested and edematous optic disk. The eye tries to protect itself from the hypertension first with arteriolar constriction and then in time with thickening of the arteriolar walls (producing the broad light reflex). The cotton wool spots are actually small, superficial foci of retinal ischemia, which occur when the arterioles squeeze down too hard. The hemorrhage and deposits occur because of vessel damage with leakage of contents. Hypertensive retinopathy can be seen in chronic essential hypertension, malignant hypertension, and toxemia of pregnancy. Treatment of the retinopathy is with control of the hypertension. (Practically, progression can be stopped and the hemorrhages will resolve, but the vessel changes remain.)
Central retinal artery occlusion (choice A) usually presents with sudden, unilateral blindness and produces a pale opaque fundus with a red fovea.
Central retinal vein occlusion (choice B) can cause painless visual loss and produces a congested and edematous fundus with numerous hemorrhages. Funduscopic examination is classically described as blood and thunder. The arteriolar changes of hypertensive retinopathy are not present.
Non-proliferative diabetic retinopathy (choice D) also causes hemorrhage and exudates in the retina, but additionally it has distinctive microaneurysms (visible as red dots).
Proliferative diabetic retinopathy (choice E) has the changes of non-proliferative diabetic retinopathy with the addition of neovascularization with vessel growth into the vitreous.
PEARL: Hypertension can result in multiple changes in the eye. Silver wiring and AV nicking are early changes that can progress and cause hypertensive retinopathy.
- Hypertensive retinopathy results from retinal arteriolar spasm and narrowing in response to longstanding hypertension.
- Silver wiring and AV nicking are the characteristic findings on retinal examination. Retinal hemorrhages suggest an associated retinal vascular accident.
- Cotton wool spots, flame hemorrhages, and disc swelling are more typical of malignant hypertension, especially in young patients.
- Control of blood pressure and lipids are the mainstay of treatment for hypertensive retinopathy, with laser treatment as determined by a retinal specialist.
