Elsevier

The Lancet Neurology

Volume 3, Issue 3, March 2004, Pages 179-183
The Lancet Neurology

Rapid Review
Is retinal photography useful in the measurement of stroke risk?

https://doi.org/10.1016/S1474-4422(04)00682-9Get rights and content

Summary

Background

The retinal microcirculation can be viewed non-invasively to give a unique perspective of the cerebral microcirculation in vivo. Studying pathological changes of retinal blood vessels (microaneurysms, retinal haemorrhages, and retinal arteriolar narrowing) may help to understand the causes of various cerebrovascular disorders. Retinal photography provides such an opportunity.

Recent developments

Several recent studies have shown that retinal microvascular changes are reliably documented by retinal photographs. These retinopathy changes seem to be fairly common in the general population, even in people without hypertension or diabetes. Retinopathy is related to incident clinical stroke and stroke mortality and to MRI-defined subclinical cerebral white-matter lesions and cerebral atrophy, independent of blood pressure, diabetes, and other cerebrovascular risk factors.

Where next?

Retinal microvascular abnormalities seem to be markers of concomitant cerebral microangiopathy, and retinal photography may be useful for the investigation of microvascular disorders of the brain in clinical and epidemiological settings. Future research should be aimed at the development of standardised photographic methods for the assessment of retinal microvascular changes, the replication of these findings in other populations and in people with other cerebrovascular disorders, and the examination of the increased accuracy of stoke-risk stratification given by retinal photography.

Section snippets

Assessment of retinal microvascular signs from retinal photographs

Retinal photography is a potentially sensitive and precise method of assessing retinal microvascular signs. This concept is supported by current studies. In general, reproducibility from photographs has been found to be excellent for well-defined retinopathy signs (kappa values have ranged from 0·80 to 0·99 for microaneurysms and retinal haemorrhages) and fair to moderate for other more subtle retinal arteriolar lesions (0·80–0·79 for arteriolar narrowing and arteriovenous nicking).11, 12, 13

Association of retinal microvascular signs and stroke

The association of retinal microvascular changes with hypertension is well known. Newer data, including those from several population-based studies, indicate that retinal microvascular changes, when defined from photographs, are associated with stroke and various cerebrovascular diseases independent of hypertension (table).8, 9, 13, 14, 19, 20, 21, 22

The Atherosclerosis Risk In Communities (ARIC) study is a population based cohort investigation of cardiovascular disease and its risk factors

Research and clinical implications

These recent studies raised the intriguing possibility that retinal photography may be useful for further understanding the association of microvascular disease with stroke and other vascular disorders of the brain. Retinal microvascular lesions are pathologically related to hypertension and diabetes severity.3 Some retinal changes, such as generalised retinal arteriolar narrowing and arteriovenous nicking, seem to be related to chronically high blood pressure,26 and systemic markers of

Future opportunities

There are several opportunities for future research. First, researchers should develop a common and standardised photographic classification of these retinal microvascular changes that is not only based on pathophysiological data, but also relevant to contemporary clinical situations. This will facilitate comparative clinical and epidemiological studies. A classification system similar to diabetic retinopathy classification is ideal. Second, it is important to replicate some of these findings

Conclusions

Improved prevention of stroke and other cerebrovascular diseases requires a greater understanding of their pathogenetic mechanisms, identification of novel risk factors, and development of new approaches to identification of people at high risk. Recent studies suggest that retinal microvascular abnormalities are markers of concomitant cerebral microvascular diseases, and that a retinal photographic examination may provide a unique method for investigating subclinical microangiopathy in people

Search strategy and selection criteria

Information for this review was identified from MEDLINE with combinations of the search terms “stroke”, “retinal photographs”, “retinal microvascular”, “retinal arteriolar”, and “retinopathy”. The search was limited to publications from 1990 to 2003, although key studies from before 1990 were also included. From the articles identified, original investigations and review articles were included. The reference lists of articles were also searched for additional relevant articles.

References (33)

  • N Aoki

    Epidemiological evaluation of funduscopic findings in cerebrovascular diseases, I: Fundoscopic findings as risk factors for cerebrovascular diseases

    Jpn Circ J

    (1975)
  • H Okada et al.

    A prospective study of cerebrovascular disease in Japanese rural communities, Akabane and Asahi, part 1: evaluation of risk factors in the occurrence of cerebral hemorrhage and thrombosis

    Stroke

    (1976)
  • K Svardsudd et al.

    Hypertensive eye ground changes: prevalence, relation to blood pressure and prognostic importance

    Acta Med Scand

    (1978)
  • H Tanaka et al.

    Epidemiologic studies of stroke in Shibata, a Japanese provincial city: preliminary report on risk factors for cerebral infarction

    Stroke

    (1985)
  • T Nakayama et al.

    A 15–5-year follow-up study of stroke in a Japanese provincial city: the Shibata Study

    Stroke

    (1997)
  • S Kobayashi et al.

    Subcortical silent brain infarction as a risk factor for clinical stroke

    Stroke

    (1997)
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