Hypertensive Retinopathy

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A comprehensive topic overview

Introduction

Hypertension (HTN) describes persistently raised arterial blood pressure and is a major risk factor for cardiovascular
disease. Long-term raised blood pressure can lead to end-organ damage to the eyes, kidneys, heart and nervous system.
1
In the eye, this manifests most commonly as a form of retinopathy and can lead to retinal vascular occlusion. The
diagnosis of hypertensive retinopathy is made clinically from characteristic fundoscopic appearances.
Malignant or accelerated hypertension describes an acute rise in blood pressure (>180mmHg systolic and >120mmHg
diastolic) causing acute end organ damage. In the eye, this manifests as swelling of the optic disc and a form of
retinopathy.
In 2015, the prevalence of hypertension in England was 31% in men and 26% in women, with more than 50% of people over
60 years a

Aetiology

There are several types of hypertension\:
2
Primary (essential)\: the most common type of HTN occurring in 90% of people where no identi
Secondary\: where a known cause is found, including kidney disease, obesity, pregnancy, endocrine disorders and drugs.
Malignant or accelerated hypertension\: severe increase in blood pressure to >180/120mmHg with signs of retinal
haemorrhage and/or papilloedema.
White-coat\: existing only when measured during medical consultation.
Masked\: existing only with ambulatory or home blood pressure measurements and not during a clinic consultation
Hypertension is conmeasuring a patient’s blood pressure.
3
Further investigations for hypertension may include\:
Tests to con
Tests to con
HTN remains the biggest risk factor for cardiovascular disease, so it must be diagnosed and managed early and
e
4
For more information, see the Geeky Medics guide to hypertension.

Clinical features

History
clinical examination.
Hypertensive retinopathy due to chronic hypertension is usually asymptomatic and can only be diagnosed through
In contrast, patients with malignant or accelerated hypertension are usually symptomatic. Typical symptoms may
include\:Intermittent blurring of vision
Visual
Headache
Flushed and red appearance of the face
Nausea and vomiting
Sudden painless loss of vision due to vessel occlusion
Signs of end-organ damage (e.g. heart failure, acute kidney injury and chest pain)
Clinical examination
Hypertensive retinopathy is a clinical diagnosis based on characteristic fundoscopy. For more information, see
our guide to fundoscopic appearances of retinal pathology.
Figure 1. Fundoscopic features of hypertensive retinopathy
Figure 2. AV nipping
There are numerous classiKeith-Wagener-Barker classi
The Keith-Wagener-Barker classi
5,6
Grade 1\: mild, generalised constriction of retinal arterioles
Grade 2\: de
Grade 3\: grade 2 with
Grade 4\: severe grade three retinopathy with papilloedema (optic disc swelling) or signs of retinal oedema
Malignant hypertension typically presents with grade four hypertensive retinopathy with evidence of papilloedema (optic
disc swelling secondary to raised intracranial pressure).
7,8
Figure 3. Malignant hypertension

Investigations

Further specialised ophthalmological investigations may be used to investigate hypertensive retinopathy including optical
coherence tomography (OCT) and intravenous

Di

An important didiabetic retinopathy as many patients with hypertension may also have type one or
type two diabetes mellitus.
Di
Typical fundoscopic
spots and neovascularisation (new vessels on the retina).

Management

The treatment for hypertensive retinopathy primarily focuses on reducing blood pressure.
Management of chronic hypertension
Management of chronic hypertension 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
Target blood pressure for patients \<80 years is a clinic blood pressure \<140/90mmHg or ABPM/HBPM
\<135/85mmHg.Target blood pressure for patients aged >=80 years is a clinic blood pressure \<150/90mmHg or ABPM
\<145/85mmHg.
Management of malignant or accelerated hypertension
Malignant or accelerated hypertension is a hypertensive emergency.
In a patient suspected of malignant or accelerated hypertension, NICE recommends referral for same-day specialist
assessment if there are\:
Signs of retinal haemorrhage and/or papilloedema on fundoscopy
Life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure or signs of acute kidney injury
If these complications are present, medical management should be started without waiting for ambulatory or home blood
pressure monitoring to con
In malignant hypertension, the aim is to reduce blood pressure over 24-48 hours. Lowering blood pressure too quickly may
result in organ hypoperfusion.
An arterial line may be inserted to allow continuous blood pressure monitoring.
Intravenous anti-hypertensives such as nitroprusside, labetalol and nicardipine may be used to further control blood
pressure.

Complications

Hypertension predisposes patients to other retinal vascular diseases, including central or branch retinal vessel occlusion.
Ischaemia secondary to vessel occlusions can lead to further complications such as neovascularisation, vitreous
haemorrhage and tractional retinal detachment.
Uncontrolled hypertension may also contribute to the progression of pre-existing diabetic retinopathy.
Delayed management of malignant hypertension may result in irreversible visual loss and changes, without treatment it
carries a 90% mortality at one year.
Most retinal changes secondary to malignant hypertension will improve within six months once hypertension is well
managed, but any arteriosclerotic changes in the retina will not regress.

Key points

Hypertension describes persistently raised arterial blood pressure and is a major risk factor for cardiovascular disease
The retina can be damaged if blood pressure rises suddenly to very high levels or if blood pressure is moderately
raised over a prolonged period of time, this is known as hypertensive retinopathy.
Hypertensive retinopathy is a clinical diagnosis with characteristic fundoscopic appearances (arteriolar narrowing, AV
nicking, hard exudates and cotton wool spots)
Grade 4 hypertensive retinopathy is diagnosed by evidence of papilloedema (optic disc swelling due to raised
intracranial pressure)
The management of hypertensive retinopathy focuses on reducing blood pressure
Delayed management of hypertensive retinopathy may result in irreversible vision loss
Complications include further retinal vascular disease and the progression of diabetic retinopathy

References

NICE CKS. H y p e r t e n s i o n C l i n i c a l K n o w l e d g e S u m m a r i e s . Wade, E. Geeky Medics. 2021. Available from\: [LINK]
July 2022. Available from\: [LINK]Potter, L. Geeky Medics. B l o o d P r e s s u r e M e a s u r e m e n t – O S C E G u i d e . November 2021. Available from\: [LINK]
NICE CKS. S c e n a r i o \: A s s e s s i n g c a r d i o v a s c u l a r r i s k . August 2020. Available from\: [LINK]
Bhagat, N. EyeWiki. H y p e r t e n s i v e R e t i n o p a t h y . June 2022. Available from\: [LINK]
Bhargava, M., Ikram, M., Wong, T. Journal of Human Hypertension. 26(2)\:71-83. H o w d o e s h y p e r t e n s i o n a
February 2012. Available from\: [LINK]
Knott, L. Patient. H y p e r t e n s i v e E m e r g e n c i e s . June 2020. Available from\: [LINK]
Tuteja, S. Geeky Medics. F u n d o s c o p i c A p p e a r a n c e s o f R e t i n a l P a t h o l o gi e s . November 2021. Available from\: [LINK]
Image references
Figure 1. Adapted by Geeky Medics. Blausen.com staCC BY 3.0].
Figure 2. Adapted by Geeky Medics. Photograph of AV nipping originally provided by Frank Wood. License\: [CC BY 3.0]
Figure 3. Adapted by Geeky Medics. Ophthalmic Atlas Images by EyeRounds.org, The University of Iowa. License\: [CC-ND-
NC 3.0]

Reviewer

Dr Anne Gobbett
Speciality Doctor in Ophthalmology
Sunderland Eye In

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Contents

Introduction
Aetiology
Clinical features
Investigations
Di
Source\: geekymedics.com