A CLINICAL STUDY ON FUNDUS CHANGES IN PREGNANCY INDUCED HYPERTENSION PATIENTS ATTENDING A TERTIARY CARE HOSPITAL-VISAKHAPATNAM

Dr. V. V. L. Narasimha Rao 1 , Dr. P. Manjula 2 and Dr. Pradhana. Divya 3 .  1. M.S., D.O., Professor of Ophthalmology, Andhra medical college, Visakhapatnam. 2. M.S., D.O., Assistant Professor, Ophthalmology, Andhra medical college, Visakhapatnam. 3. MBBS, Junior Resident, Ophthalmology, Andhra medical college, Visakhapatnam. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


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Retinal changes that occur are mainly in correlation with the severity of hypertension. These changes are reversible most of the times . (4,11). As the blood pressure rises in pregnancy-induced hypertension, the effects of the BP are most easily seen in the fundus of the patients with PIH.
Hence the study is aimed at fundus examination of the patients with PIH, assessment of the retinal changes and determining the correlation between the fundus changes, blood pressure and the severity of the disease.

Materials and methods:-
In this observational cross-sectional study,35 patients with pregnancy-induced hypertension were included, which was carried out during October 2017 -november 2017 at tertiary care hospital, Visakhapatnam blood pressure at the time of diagnosis, proteinuria (if any), were noted from the patient's records.  Detailed ophthalmic history was taken regarding the complaints like blurring of vision, sudden loss of vision or previous such episodes, etc.,  Patients visual acuity for far was noted using the Snellen chart.  Examination of the anterior segment was done, and the pupil reactions were assessed.
Tropicamide+phenylepherine eye drops were instilled in both eyes for the dilatation of the pupil. Posterior segment evaluation was done. The fundus findings were noted.  The fundus findings were graded according to the Keith-Wegner classification (7) into: Grade I-mild generalized arterial attenuation, particularly of small branches; Grade II-more severe grade I+focal arteriolar attenuation; Grade III-grade II+haemorrhages, hard exudates, cotton wool spots; Grade IV-grade III+optic disc swelling(papilledema) (7).  The severity of the PIH was classified as gestational hypertension, pre-eclampsia and eclampsia according to their clinical definitions.

Statistics:
The data obtained was analyzed, and chi-square test was used. A p-value of <0.05 is taken as significant.
Results:- The mean age of the patients included in the study is 23.26 years. With the minimum age at 20years to the maximum at 27 years.  Of the 35, 12 patients were primi gravida, and 23 were multi gravida, with gestational age ranging from 24weeks to 38weeks.  3 patients of 35 complained of gross fall of vision with sudden onset which persisted >2days.  12 patients complained of the transient loss of vision ranging from 3min.-10minutes.  20 patients have no visual complaints.  Of these patients with visual complaints, 13 were associated with headaches.  17 patients had PIH in their previous pregnancy. Of which 9 patients had the history of visual complaints and PIH during their previous pregnancies. Of these patients, blood pressure recordings varied.
153   6(17.14%) 6 0 Fundus changes are correlating with the rise in blood pressure. 13 patients were diagnosed with gestational hypertension, 13 were with pre-eclampsia and 9 patients with eclampsia. When compared with the severity of the disease and the presence of fundus changes The results showed that as severity of the disease increased the presence of fundus changes also increased, this correlation is statistically significant.

Discussion:-
In this study there are about 66% multigravida patients and 34% of primi gravid, of these patients, gestational hypertension was diagnosed in 37.14%, which is in equal percent to the pre-eclampsia patients. Eclampsia patients were less when compared to the above two categories in the severity of the disease.
Fundus changes due to PIH were noted in about 63 % patients, and no changes were noted in the remaining 37% of the patients. Increased incidence of Fundus changes due to PIH was noted with increasing severity of the disease.
Fundus changes noted are grade 1 hypertensive changes in 31.4%, grade 2 hypertensive changes in 22.8% whereas there are no patients with grade 3 and grade 4 changes. This may be due to early diagnosis of the disease and the immediate start of the treatment, as the patients included in the study were all the booked cases with regular ante natal check-ups.

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3 cases out of 35 cases showed reduced visual acuity, on fundus examination, CSCR was noticed in these cases. 34.28% cases complained about the transient blurring of vision and remaining 57.1% cases have no visual complaints.
Of the cases with no visual complaints, some cases have grade 1 or grade 2 hypertensive changes. Visual acuity is not effected in any of the above cases as there is no macular involvement in these cases.
When compared with the severity of the disease and presence of the fundus changes, the statistical significance is observed.
40% of patients had 140/90 -150/100 mmHg blood pressure of which 5 patients had retinal changes.42.8% had 150/100-160/100 mm of hg BP, of which 11 patients had fundus changes17.1% had >160/100 mmHg BP, 7 of these patients had changes. Even though there is increases incidence of fundus changes with the increase in blood pressure, there are also cases with no retinal changes with that range of blood pressure.
In a study by Jaffe and Schatz [13] ,it is reported that there is a significant correlation between the reduction in arteriole to vein ratio, number of focal arteriolar constrictions and severity of preeclampsia. They did not find any hemorrhages, exudates, cotton wool spots, or retinal detachment in their study of 17 mild preeclampsia and 14 severe preeclampsia patients., the present study has similar results to this study.
In a study of Reddy (12) has reported retinal changes in 53.4% preeclampsia and in 71.2% in eclampsia patients, The most common fundus change was narrowing of arterioles. He found that retinal changes were significantly more in patients with severe hypertension. In the current study, there are more of gestational hypertensives and pre eclamptic patients compared to the above study, but the incidence of fundus changes with the severe hypertension is similar to the above study.

Conclusion:-
Visual symptoms are less in patients with PIH and are absent unless the macula is involved.
The retinal changes due to PIH are significantly correlated with the severity of the disease and level of blood pressure.
Early diagnosis and immediate treatment of the disease prevents further changes in the fundus.
Routine ophthalmoscopic examination of PIH cases for an assessment of the vascular changes should be done.Thereby the severity of the disease can be assessed, which is useful in the prevention of maternal morbidity and mortality.