Hypertensive Retinopathy

Hypertensive Retinopathy

Eye & Vision
Diseases & Conditions
Contributed byKrish Tangella MD, MBAOct 07, 2018

What are the other Names for this Condition? (Also known as/Synonyms)

  • HR (Hypertensive Retinopathy)
  • Malignant Hypertension causing Retinopathy
  • Stage 1 Hypertensive Retinopathy

What is Hypertensive Retinopathy? (Definition/Background Information)

  • Hypertensive Retinopathy (HR) refers to abnormal changes of the retina that is located in the back of the eye, due to chronic hypertension (high blood pressure)
  • The retinal arteries are autoregulated, meaning they can control their own shape based on changes in systemic blood pressure. However, at extremely high blood pressures, such as a blood pressure of 140/110 mmHg or over, they are unable to autoregulate. This can result in retinal complications
  • Depending on the severity of the signs and symptoms, Hypertensive Retinopathy can be classified to 4 stages - stage 1, 2, 3, and 4. Stage 1 Hypertensive Retinopathy has mild signs and symptoms, whereas Stage 4 Hypertensive Retinopathy has severe signs and symptoms
  • These changes typically occur in individuals who have had very high blood pressure for several years. The signs and symptoms of Hypertensive Retinopathy may include leakage of fats from the blood vessels, retinal edema (fluid in the retina), and swelling of the optic nerves
  • Some of the complications can include lack of oxygen delivered to the retina, as well as swelling of the macula and optic nerve that can result in the vision being affected
  • The treatment typically consists of controlling systemic hypertension with medications. Prognosis is generally good for individuals with stage 1 or 2 Hypertensive Retinopathy

Who gets Hypertensive Retinopathy? (Age and Sex Distribution)

  • Elderly adults are most likely to have uncontrolled hypertension compared to other age groups, increasing the risk for developing Hypertensive Retinopathy
  • However, individuals of any age affected by uncontrolled high blood pressure may develop the condition
  • Men and women are almost equally affected
  • Africans: The prevalence of Hypertensive Retinopathy is higher among African countries, since they are most affected by uncontrolled hypertension, which increases the risk for developing HR
  • Individuals with chronic hypertension: It is estimated that roughly 40% of the world population over the age of 25 years has high blood pressure. And, approximately 1 billion people worldwide have uncontrolled hypertension

What are the Risk Factors for Hypertensive Retinopathy? (Predisposing Factors)

The risk factors for developing Hypertensive Retinopathy include:

  • Longstanding increased blood pressure (chronic hypertension)
  • Systemic blood pressure of typically 140/110 mmHg (minimum) for advanced stages of Hypertensive Retinopathy to manifest
  • Systemic blood pressure of typically 180/120 mmHg (minimum) for malignant stage (stage 4) of Hypertensive Retinopathy to manifest, which includes severe hemorrhaging and/or swelling of the optic nerve

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Hypertensive Retinopathy? (Etiology)

Hypertensive Retinopathy is caused by an increased blood pressure (BP) in the blood vessels within the retina. This increased or high BP damages the small retinal blood vessels in a variety of ways.

  • Chronic hypertension causes the blood vessels to change shape, when they are no longer able to control their own shape via autoregulation. The abnormal changes in blood vessel shape includes narrowing and crossing of the arteries and veins
  • Once the blood vessels change shape, they are more prone to leaking blood consisting of fats and fluids, which can cause swelling of the macula and optic nerve
  • Swelling in other areas of the retina can cause a retinal detachment

What are the Signs and Symptoms of Hypertensive Retinopathy?

The main symptom of Hypertensive Retinopathy is altered vision. When an eye specialist examines the eye using specialized equipment, the following signs may be noted:

  • Tortuosity of the retinal blood vessels (twisted blood vessels)
  • Focal narrowing of the retinal blood vessels (arteries and veins start to cross)
  • Hemorrhaging (bleeding) in the retina
  • Cotton wool spots: Yellowish areas of the retina that have decreased oxygen from lack of blood flow
  • Exudates (lipids, or fats, that have leaked from the blood vessels): This usually occurs in a star configuration around the macula, which can indicate swelling of the macula and cause vision loss
  • Retinal edema (swelling of the retina in other areas), which can lead to retinal detachment and vision loss
  • Papilledema (swelling of the optic nerves); a condition that requires immediate hospitalization

How is Hypertensive Retinopathy Diagnosed?

Hypertensive Retinopathy can be diagnosed and classified into different stages; there are several classification systems, but the following is a basic summary. The stages are classified by a healthcare specialist after a thorough examination of the eye.

  • Stage 1 Hypertensive Retinopathy: Tortuosity (curving) and/or diffuse narrowing of the retinal arteries
  • Stage 2 Hypertensive Retinopathy: Focal narrowing of the retinal arteries; arteries start to cross with veins
  • Stage 3 Hypertensive Retinopathy: Stage 2 findings, in addition to bleeding in the retina or cotton wool spots (oxygen-deprived areas of the retina) or exudates (lipid leakage)
  • Stage 4 Hypertensive Retinopathy: It can also be classified as malignant hypertension; stage 3 findings in addition to papilledema (swelling of the optic nerves) are observed

Hypertensive Retinopathy is diagnosed using the following methods:

  • Complete physical examination and medical history analysis
  • Obtaining a blood pressure reading
  • Thorough examination of the retina via the following:
    • Slit lamp examination
    • Ophthalmoscopy (observation with a special lens)
    • Retinal camera
    • Fluorescein angiography (observation using a specialized monitor after injecting dye into the bloodstream)

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Hypertensive Retinopathy?

Complications due to Hypertensive Retinopathy may include:

  • Retinal detachment (due to swelling of the retina)
  • Optic nerve atrophy, which is permanently damaged optic nerves due to swelling of the optic nerves
  • Occlusion of the retinal arteries or veins
  • Ischemia (lack of oxygen delivered to the retina due to occlusion/obstruction of the retinal arteries)
  • Retinal arterial macroaneurysms and vitreous hemorrhaging (different forms of severe bleeding)

All the above complications can lead to vision loss.

How is Hypertensive Retinopathy Treated?

The treatment measures for Hypertensive Retinopathy may include:

  • Managing the systemic blood pressure with any wide-range of treatment options available for hypertension
  • Administering injections to the eye to control swelling and preserve vision (in the case of macular edema)
  • Repair/reattachment of the retina via surgery; in case of retinal detachment

How can Hypertensive Retinopathy be Prevented?

Hypertensive Retinopathy can be prevented by undertaking routine visits to one’s primary care physician to control blood pressure. The various ways to avoid developing a hypertension (high blood pressure) include lifestyle factors such as:

  • Maintaining a healthy weight
  • Eating a diet low in salt and low in fat
  • Exercising regularly
  • Smoking cessation, limiting the intake of alcohol
  • Taking BP medications regularly
  • Managing stress using certain relaxation techniques

What is the Prognosis of Hypertensive Retinopathy? (Outcomes/Resolutions)

  • Prognosis is generally good for individuals with stage 1 or stage 2 Hypertensive Retinopathy; vision can easily be preserved with control of systemic blood pressure
  • Individuals with stage 3 or 4 Hypertensive Retinopathy are at significantly increased risk of vision loss depending on extent of damage to either the macula or the optic nerve
  • If Hypertensive Retinopathy leads to retinal detachment or occlusion of an artery or vein, the possibility of a permanent vision loss is high
  • Vision loss from Hypertensive Retinopathy is rare, and usually will only occur if blood pressure has remained at very high levels for several years

Additional and Relevant Useful Information for Hypertensive Retinopathy:

  • If the condition is diagnosed during stage 1 or 2, the progress to stages 3 and 4 Hypertensive Retinopathy can easily be prevented by following up with an eye doctor and primary care physician as directed
  • The signs and symptoms of Hypertensive Retinopathy can be similar to the signs of diabetic retinopathy. The two conditions can be differentiated and properly diagnosed with a thorough workup of the individual
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Krish Tangella MD, MBA

Pathology, Medical Editorial Board, DoveMed Team


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