FFinalistSouthampton · 2027
Ophthalmology
AKT · Ophthalmology/Retina & vitreous

Hypertensive retinopathy

Retinal vascular changes from chronic/accelerated hypertension

Overview

Retinal microvascular changes caused by hypertension, graded (Keith-Wagener-Barker) from arteriolar narrowing through AV nipping and flame haemorrhages/cotton-wool spots to papilloedema (malignant/accelerated hypertension). Usually asymptomatic; finding it should prompt BP assessment and, with papilloedema, urgent treatment.

Recognise

  • Usually asymptomatic; found on fundoscopy/screening
  • Grade 1: arteriolar narrowing/silver-copper wiring · Grade 2: AV nipping · Grade 3: flame haemorrhages, cotton-wool spots, hard exudates (macular star) · Grade 4: + papilloedema
  • Accelerated/malignant hypertension: very high BP + papilloedema/retinal haemorrhages → emergency

Red flags

  • Papilloedema/retinal haemorrhages with very high BP (≥180/120) = malignant hypertension → same-day assessment for end-organ damage
  • Headache, visual symptoms with grade 3–4 changes → urgent

Differentials & how to tell them apart

Diabetic retinopathymicroaneurysms and neovascularisation; hypertensive changes are AV nipping/arteriolar narrowing (they often coexist)
Retinal vein occlusionacute unilateral haemorrhages; hypertensive changes are bilateral and chronic
Papilloedema from raised ICPbilateral disc swelling without the hypertensive AV changes — different cause
Hypertensive retinopathy — AV nipping, haemorrhages, cotton-wool spots

Hypertensive retinopathy — AV nipping, haemorrhages, cotton-wool spots

Frank Wood / CC BY 3.0 — Wikimedia Commons

Investigations

Fundoscopy/retinal photography; measure BP and assess end-organ damage (urinalysis, renal function, ECG); investigate secondary hypertension if young/severe.

Management

Control blood pressure (urgent if malignant hypertension with papilloedema)

  1. 1Measure and manage BP per the hypertension pathway; assess for other end-organ damage.Gate: Grade 4 (papilloedema) with very high BP = malignant/accelerated hypertension → SAME-DAY assessment and controlled BP reduction, not routine titration
  2. 2Investigate secondary causes if young/resistant; ongoing BP control reverses early changes.
Antihypertensive therapy — per NICE hypertension pathway; controlled lowering in malignant hypertension

Key points

AV nipping and arteriolar narrowing are the chronic signs; papilloedema with very high BP is the emergency. The retina is a window onto systemic vascular damage.

Monitor & prognosis

BP control and end-organ surveillance.

Early changes reversible; malignant hypertension is dangerous.

Source: NICE CKS Hypertension; Keith-Wagener-Barker grading