20/4/2017 HypertensiveRetinopathyEyeDisordersMSDManualProfessionalEdition

MSDMANUAL Professional Version

Professional / EyeDisorders / RetinalDisorders

Hypertensive
Retinopathy
By Sonia Mehta, MD, Assistant Professor, Vitreoretinal Diseases
and Surgery Service, Wills Eye Hospital, Department of
Ophthalmology, Thomas Jefferson University Hospital

Hypertensive retinopathy is retinal vascular damage caused by hypertension. Signs usually

develop late in the disease. Funduscopic examination shows arteriolar constriction,
arteriovenous nicking, vascular wall changes, ame-shaped hemorrhages, cotton-wool spots,
yellow hard exudates, and optic disk edema. Treatment is directed at controlling BP and, when
vision loss occurs, treating the retina.

Pathophysiology
Acute BP elevation typically causes reversible vasoconstriction in retinal blood vessels, and
hypertensive crisis may cause optic disk edema. More prolonged or severe hypertension leads to
exudative vascular changes, a consequence of endothelial damage and necrosis. Other changes
(eg, arteriole wall thickening, arteriovenous nicking) typically require years of elevated BP to
develop. Smoking compounds the adverse effects of hypertensive retinopathy.

Hypertension is a major risk factor for other retinal disorders (eg, retinal artery or vein occlusion,
diabetic retinopathy). Also, hypertension combined with diabetes greatly increases risk of vision
loss. Patients with hypertensive retinopathy are at high risk of hypertensive damage to other end
organs.

Symptoms and Signs

Symptoms usually do not develop until late in the disease and include blurred vision or visual
eld defects.

In the early stages, funduscopy identies arteriolar constriction, with a decrease in the ratio of
the width of the retinal arterioles to the retinal venules.

Chronic, poorly controlled hypertension causes the following:

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Permanent arterial narrowing

Arteriovenous crossing abnormalities (arteriovenous nicking)

Arteriosclerosis with moderate vascular wall changes (copper wiring) to more severe
vascular wall hyperplasia and thickening (silver wiring)

Sometimes total vascular occlusion occurs. Arteriovenous nicking is a major predisposing factor
to the development of a branch retinal vein occlusion.

If acute disease is severe, the following can develop:

Supercial ame-shaped hemorrhages

Small, white, supercial foci of retinal ischemia (cotton-wool spots)

Yellow hard exudates

Optic disk edema

Yellow hard exudates represent intraretinal lipid deposition from leaking retinal vessels. These
exudates can develop a star shape within the macula, particularly when hypertension is severe.
In severe hypertension, the optic disk becomes congested and edematous (papilledema
indicating hypertensive crisis).

Diagnosis
Diagnosis is by history (duration and severity of hypertension) and funduscopy.

Hypertensive Retinopathy (Copper Wiring)

Image courtesy of Prof. J. Wollensak via the Online Journal of Ophthalmology (www.onjoph.org).

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Hypertensive RetinopathyModerate (Vessel Changes and Cotton-Wool Spots)

Images courtesy of Prof. J. Wollensak via the Online Journal of Ophthalmology (www.onjoph.org).

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Hypertensive RetinopathyMalignant (Star-Shaped Exudates and Papilledema)

Images courtesy of Prof. J. Wollensak (top) and the Ophthalmic Clinic of the Health Center of the
University of Erlangen-Nrnberg (bottom), via the Online Journal of Ophthalmology
(www.onjoph.org).

Treatment
Hypertensive retinopathy is managed primarily by controlling hypertension. Other vision-
threatening conditions should also be aggressively controlled. If vision loss occurs, treatment of
the retinal edema with laser or with intravitreal injection of corticosteroids or antivascular
endothelial growth factor drugs (eg, ranibizumab, pegaptanib, bevacizumab) may be useful.

Key Points

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Chronic hypertension progressively damages the retina, causing few or no symptoms until
changes are advanced.

Chronic hypertensive retinopathy is recognized by permanent arterial narrowing,

arteriovenous crossing abnormalities (arteriovenous nicking), arteriosclerosis with
moderate vascular wall changes (copper wiring), or more severe vascular wall hyperplasia
and thickening (silver wiring).

Hypertensive crisis can cause retinopathy with supercial ame-shaped hemorrhages;

small, white, supercial foci of retinal ischemia (cotton-wool spots); yellow hard exudates;
and optic disk edema.

Diagnose patients by history and funduscopy.

Treat primarily by controlling BP, and, for retinal edema, sometimes laser or intravitreal
injection of corticosteroids or antivascular endothelial growth factor drugs.

Last full review/revision January 2017 by Sonia Mehta, MD

2017 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA

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