Welcome to question of the day #204

Welcome to question of the day #204

I have taken some retinal photographs of one of my patients. He is 59 and looks to be overweight but tells me he doesn’t take any medicine and as far as he is aware his general health is fine. The photographs indicate bends in his retinal arteries. I confirmed this with direct ophthalmoscopy. What should I do?

I can see from the photographs that the retinal arteries in each eye are tortuous. Tortuosity means twistedness or crookedness. It may be that some of the retinal veins have slight tortuosity but that is more difficult to confirm from the photographs.

It is important to have a close look at the retinal vessels during the examination. Changes in the shape, colour, and width of vessels can represent ocular signs of systemic conditions. Examining retinal vessels can assist in diagnosing vascular abnormalities.

When I was at optometry school I was taught that tortuous blood vessels were a definite sign of systemic vascular disease. However, over the years, the significance of tortuous retinal arterioles has been debated. Some studies suggest that tortuosity may be strongly associated with systemic vascular conditions, and others have disproved this theory and have found no apparent correlation. One study showed that older age, higher blood pressure, alcohol consumption, greater BMI, diabetes, and higher HbA1c level are associated with less tortuous retinal arterioles. Another study suggested that straighter retinal arterioles were associated with higher blood pressure and BMI. However, two other studies associated elevated blood pressure with increased retinal arteriolar tortuosity. Seems that more and larger studies are needed to determine the relationship between retinal artery tortuosity and vascular diseases.

However, while we wait for these studies to help us, in the meantime your patient deserves a referral to his general medical practitioner to have his blood pressure measured. Of course, explain to your patient your concerns and keep a note of everything you have done and said.