Hypertensive Retinopathy

Hypertensive Retinopathy

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Hypertension (HTN) is a significant risk factor for cardiovascular disease and is characterized by persistently high arterial blood pressure. Long-term elevation of blood pressure can lead to end-organ damage to the eyes, kidneys, heart and nervous system.

In the eye, this is commonly seen in the form of retinopathy and can lead to retinal vascular occlusion. Hypertensive retinopathy is diagnosed based on certain fundoscopic appearances.

Malignant or accelerated hypertension is a sudden rise in blood pressure (above 180mmHg systolic and 120mmHg diastolic) which causes rapid end-organ damage. This manifests as swelling of the optic disc and a specific form of retinopathy.

Statistics show that in 2015, 31% of men and 26% of women in England had hypertension, with more than half of those over 60 years of age affected. 10% of the adult population had hypertensive retinopathy.


There are a few different types of hypertension: primary or essential (90%), secondary (caused by other medical issues), malignant or accelerated (sudden, severe increase in blood pressure), white-coat (only diagnosed during a medical consultation) and masked (only seen on home or ambulatory blood pressure measurements).

Hypertension is typically diagnosed by measuring a patient's blood pressure.

Further investigations may include tests to confirm end-organ damage (e.g. urinalysis, ECG and U&Es) and tests to determine the cause of hypertension.

HTN is the leading risk factor for cardiovascular disease and must be identified and managed appropriately.

Clinical features


Hypertensive retinopathy caused by chronic hypertension usually has no symptoms and is only detected on clinical examination. However, those with malignant or accelerated hypertension are usually symptomatic. Common symptoms include blurred vision, visual field defects, headache, nausea/vomiting, flushed face and sudden, painless vision loss.

Clinical examination

Hypertensive retinopathy is a clinical diagnosis based on characteristic fundoscopic appearances.

Fundoscopic Appearances of Retinal Pathologies

There are numerous classification systems used to stage hypertensive retinopathy due to chronic hypertension.

Keith-Wagener-Barker Classification of Hypertensive Retinopathy

The Keith-Wagener-Barker classification grades hypertensive retinopathy as follows:

  • Grade 1: Mild, generalised constriction of retinal arterioles
  • Grade 2: Definite focal narrowing of retinal arterioles and AV nicking
  • Grade 3: Grade 2 with flame-shaped haemorrhages, cotton-wool spots and hard exudates.
  • Grade 4: Severe Grade 3 retinopathy with papilloedema (optic disc swelling) or signs of retinal oedema

Malignant hypertension typically presents with Grade 4 hypertensive retinopathy with evidence of papilloedema (optic disc swelling secondary to raised intracranial pressure).

Malignant Hypertension

Investigations to investigate hypertensive retinopathy can include optical coherence tomography (OCT) and intravenous fluorescein angiography (IVFA).

When considering hypertension, an important differential to consider is diabetic retinopathy due to many patients with hypertension having type one or type two diabetes mellitus. Differences between these conditions can be distinguished through clinical history and examination findings. Typical fundoscopic findings in diabetic retinopathy include microaneurysms, dot and blot haemorrhages, cotton wool spots, and neovascularisation (new vessels on the retina).


The treatment for hypertensive retinopathy primarily focuses on reducing blood pressure.

Management of Chronic Hypertension

Chronic hypertension management may be split into conservative and medical management. Conservative measures include lifestyle changes (e.g. healthy diet, regular exercise, and reduced alcohol and smoking). Medical management includes oral antihypertensives (e.g. ACE inhibitors, angiotensin receptor blockers, and calcium channel blockers).

Blood Pressure Targets
  • For patients under 80 years old, the target blood pressure is a clinic blood pressure below 140/90mmHg or ABPM/HBPM below 135/85mmHg.
  • For patients 80 and older, the target blood pressure is a clinic blood pressure below 150/90mmHg or ABPM below 145/85mmHg.

Management of Malignant or Accelerated Hypertension

Malignant or accelerated hypertension is considered a hypertensive emergency. In a patient suspected of having this type of hypertension, same-day specialist assessment is recommended by NICE if there are signs of retinal hemorrhage and/or papilloedema on fundoscopy, life-threatening symptoms (e.g. confusion, chest pain, heart failure signs, acute kidney injury signs), etc. Medical management should be started immediately without waiting for ambulatory or home blood pressure monitoring to confirm. The aim is to reduce blood pressure over 24-48 hours, and an arterial line may be inserted to allow continuous blood pressure monitoring. Lowering the blood pressure too quickly could result in organ hypoperfusion.

Intravenous Anti-Hypertensives

Intravenous anti-hypertensives, such as nitroprusside, labetalol and nicardipine, may be used to further control blood pressure.

Fundoscopic Appearances of Retinal Pathologies

Fundoscopic appearances of retinal pathologies are used to identify and diagnose potential eye conditions. This article will explore three of the most commonly observed abnormalities seen through a fundoscope.

Retinal Artery Nipping

Retinal artery nipping, also known as 'arteriolar narrowing', is a condition which appears as a white crescent-shaped narrowing at the arteriovenous junction. It is a common sign of hypertensive retinopathy and is often seen in patients with high blood pressure.

Arteriovenous Nipping

Arteriovenous nipping is another sign of hypertensive retinopathy and appears as a crescent-shaped narrowing at the arteriovenous crossing. It is caused by increased vascular resistance of the retinal arterioles, which is a common feature of hypertensive retinopathy.

AV nipping fundoscopy image

Acute Retinal Exudate

Acute retinal exudate is a sign of diabetic retinopathy and appears as white or gray patches of exudates located within the retina. It is caused by a disruption in the blood-retinal barrier, which is a common feature of diabetes.

Retinal artery exudate

These are some of the most common fundoscopic abnormalities which can be identified through a fundoscope. This article has discussed the appearance and causes of three of the most commonly observed retinal pathologies.


Hypertension increases a person's risk of other retinal vascular diseases, such as central or branch retinal vessel occlusion. This can lead to neovascularisation, vitreous haemorrhage and tractional retinal detachment. Uncontrolled hypertension can also contribute to the progression of pre-existing diabetic retinopathy.

If treated late, malignant hypertension can cause irreversible visual loss and changes, and carries a 90% mortality at one year. Most retinal changes due to malignant hypertension will improve within six months once hypertension is managed, but any arteriosclerotic changes in the retina will not regress.

Key Points

  • Hypertension is when arterial blood pressure is persistently high and is a major risk factor for cardiovascular disease.
  • Hypertensive retinopathy is damage to the retina caused by high blood pressure suddenly reaching very high levels, or by moderately raised pressure over a prolonged period of time.
  • Hypertensive retinopathy is a clinical diagnosis with characteristic fundoscopic appearances.
  • Grade 4 hypertensive retinopathy can be diagnosed by evidence of papilloedema.
  • Management focuses on reducing blood pressure.
  • Delayed management can result in irreversible vision loss.
  • Complications include further retinal vascular disease and the progression of diabetic retinopathy.


  1. NICE CKS. Hypertension Clinical Knowledge Summaries. July 2022. Available from: [LINK]
  3. NICE CKS. Scenario: Assessing cardiovascular risk. August 2020. Available from: [LINK]
  5. Bhagat, N. EyeWiki. Hypertensive Retinopathy. June 2022. Available from: [LINK]
  7. Bhargava, M., Ikram, M., Wong, T. Journal of Human Hypertension. 26(2):71-83. How does hypertension affect your eyes? February 2012. Available from: [LINK]
  9. Knott, L. Patient. Hypertensive Emergencies. June 2020. Available from: [LINK]

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