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Hypertensive Retinopathy

ROUTINE — Retina

Symptoms

usually asymptomatic (detected on routine fundus exam)

decreased vision possible in grade 3–4

acute headache, visual obscurations, or neurologic deficits suggest hypertensive emergency

Clinical Findings

Keith-wagener-barker (kwb) classification

  • grade 1: generalized retinal arteriolar narrowing; a:v ratio drops from 2:3 toward 1:2
  • grade 2: a/v nicking (gunn sign), venous banking, and copper/silver-wiring sclerosis
  • grade 3: hemorrhages (flame-shaped), cotton-wool spots, hard exudates, and macular star
  • grade 4: grade 3 changes plus optic disc edema (papilledema); defines hypertensive emergency

Hypertensive choroidopathy

  • elschnig spots: hyperpigmented scars with depigmented rings (focal infarction)
  • siegrist streaks: linear hyperpigmentation along sclerotic choroidal vessels
  • common in acute htn (preeclampsia, pheochromocytoma)

Other signs

  • hypertensive optic neuropathy: bilateral disc edema with macular star
  • serous retinal detachment: bilateral exudative detachments (common in eclampsia)
  • grade 3–4 correlates with nephropathy, lvh, and high stroke mortality

Etiology

Primary

  • essential hypertension (~90% of cases)

Secondary

  • renal: parenchymal disease or renal artery stenosis
  • endocrine: pheochromocytoma, cushing syndrome, or conn syndrome
  • pregnancy: pre-eclampsia and eclampsia
  • drug-induced: cocaine, amphetamines, nsaids, or oral contraceptives

Red Flags

grade 4 retinopathy (disc edema): represents a hypertensive emergency

pregnancy with retinopathy signs (emergent ob referral for eclampsia)

acute severe htn with neurologic signs (rule out hemorrhage or pres)

accelerated htn in a young patient (secondary causes)

Investigations

Bedside and ocular

  • blood pressure measurement in both arms
  • dilated fundus exam to grade kwb stage

Systemic (grade 3–4)

  • bmp (cr/bun), urinalysis (proteinuria), and ecg/echo (lvh)

Secondary screening

  • renal mra/cta, plasma metanephrines, or 24-hour aldosterone:renin ratio
  • polysomnography for obstructive sleep apnea

Treatment

Hypertensive emergency

  • inpatient admission for urgent bp control
  • target: reduce mean arterial pressure (map) by ~25% over several hours
  • warning: avoid rapid normalization to prevent watershed stroke or naion

Long-term management

  • treat underlying secondary causes (e.g., pheochromocytoma)
  • coordinate chronic control with pcp to prevent vein occlusions and naion

Clinical Pearl

Malignant hypertension (BP >180/120 with organ damage) requires emergency BP reduction — but not to normal (cerebral autoregulation requires staged reduction). Keith-Wagener-Barker (KWB) grading: Grade 3 = hemorrhages/cotton wool spots; Grade 4 = papilledema. Choroidal disease (Elschnig spots, Siegrist streaks) in malignant hypertension indicates choroidal ischemia.

Differential Diagnosis

  • diabetic retinopathy
  • anemia
  • radiation retinopathy
  • central retinal vein occlusion (crvo)

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