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Speaker: Managing hypertension an opportunity for interprofessional communication
PHILADELPHIA – Maynard L. Pohl, OD, FAAO, urged optometrists to join the team managing the hypertensive patient, in a presentation here at Optometry’s Meeting.
“Spend some extra time communicating interprofessionally,” Pohl said. “It’s a wonderful opportunity to actually talk to the physician.”
He recommended reaching out via written correspondence or even an email to inform the primary care physician that the patient will be returning to you for evaluation of their eyes.
“If you refer the patient to the retinal specialist and the family doctor, send a letter of introduction to the retinal specialist and copy the primary care physician and keep them in the loop,” he said.
Pohl said that by “going the extra mile,” your portfolio of providers and care you provide will automatically increase.
He discussed the various ocular manifestations of vascular disease, including hypertensive retinopathy, venous occlusive disease, arterial occlusive disease and diabetic retinopathy, and why it is essential for optometrists to understand these conditions.
“As optometrists, if we already know what the patient has when we look at their eye findings, the easy part is managing or triaging their care,” he said.
“Sixty million Americans have systemic hypertension,” Pohl continued. “And there are 1 billion worldwide. A normotensive American at age 55 has a 90% lifetime risk of developing hypertension. Systemic hypertension will never kill anyone, but it’s what it does to the target organs. I always say that the eyes are the most important, but we also need our heart and our brain. We can identify cardiac disease and stroke, and in the eyes we see the manifestations of these conditions.”
He further broke down the ocular manifestations and identified how they become evident in the eyes.
Hypertensive retinopathy, Pohl said, is divided into the vasoconstrictive phase, exudative phase, sclerotic phase and complications of the sclerotic phase.
“If we have an increase in blood pressure and we control that blood pressure in a timely fashion, we may not get any changes to the fundus,” he said. “But even longstanding hypertension that is well controlled can result in a vasculopathy or change to the blood vessel.”
As detailed by Pohl, hypertensive choroidopathy can involve Elschnig’s spots, Siegrist streaks and large patches of chorioretinal atrophy.
“The blood pressure goes up really, really high and the choroid vasculature, the choroid capillaries – this is not under autoregulatory control,” he said. “This is under autonomic control. This is where the parasympathetic and the sympathetic control is present in the choroidal vasculature. There are a lot of fenestrations and there are not as many branches in the choroid. The blood pressure goes up really high and results in endarteritis fibrosa.
“Basically, this is a response to increased pressure where the choroid is being insulted and you get yellow and sclerosed choroidal vessels,” Pohl explained.
Increased intracranial pressure and ischemia is evidence of hypertensive optic disc edema, he noted.
“Hypertensive optic disc edema occurs with high blood pressure, but patients can be asymptomatic,” he said. “The high systemic hypertension will typically cause the optic nerve to swell.”
In dealing with these various conditions, Pohl admonished colleagues to take a larger role in hypertension management as well as use the opportunity as a means to improve comanagement skills.
“Blood pressure management is key, as well as referral to the family physician or internist, depending on the severity of the hypertension,” Pohl said. “Monitor the fundus at least every 12 months and absolutely invite the opinion of the retinal specialist. Counsel your patient; explain what you’re seeing and how and why the eyes are changing.
“The comanagement team is the optometrist, the ophthalmologist, the vitreoretinal specialist and family medicine or internal medicine,” he concluded. “Work as a team to provide the best care you can to your patients.” – by Chelsea Frajerman