Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Ocular effects of hypertension

Norman M Kaplan, MD
Raymond R Townsend, MD
Section Editor
George L Bakris, MD
Deputy Editor
John P Forman, MD, MSc


A number of ocular abnormalities are directly or indirectly associated with hypertension [1,2]. These include some that are a direct consequence of elevated blood pressure, including hypertensive retinopathy, choroidopathy, and optic neuropathy. With other abnormalities, hypertension is a significant risk factor, including retinal vein and artery occlusion, retinal artery emboli, and diabetic retinopathy. In addition, hypertension may accelerate nonvascular eye disease, including age-related macular degeneration and glaucoma.


Fundoscopy should be part of the physical examination on every patient with newly diagnosed hypertension since the retina is the only part of the vasculature that can be visualized noninvasively. Pupillary dilatation with a short-acting mydriatic (eg, tropicamide 1%) is almost always useful since the mild changes are hard to quantify, even with retinal photography [3]. (See "Initial evaluation of the hypertensive adult", section on 'Physical examination'.)

The most common ocular diseases directly related to hypertension are progressively increasing retinal microvascular changes, which are subsumed under the name "hypertensive retinopathy." Classically, the features are divided into four degrees, and their morphological classification has been widely used [4]. However, a more pathophysiological division has been proposed and seems more logical [3]. This three-degree classification includes mild, moderate, and severe (image 1):

Mild – Retinal arteriolar narrowing related to vasospasm, arteriolar wall thickening or opacification, and arteriovenous nicking, referred to as "nipping" (image 1) [3].

Moderate – Hemorrhages, either flame or dot-shaped, cotton-wool spots, hard exudates, and microaneurysms (image 1).


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Sep 8, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Wong TY, Mitchell P. The eye in hypertension. Lancet 2007; 369:425.
  2. Gudmundsdottir H, Taarnhøj NC, Strand AH, et al. Blood pressure development and hypertensive retinopathy: 20-year follow-up of middle-aged normotensive and hypertensive men. J Hum Hypertens 2010; 24:505.
  3. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004; 351:2310.
  4. Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: their course and prognosis. Am J Med Sci 1974; 268:336.
  5. Sharrett AR, Hubbard LD, Cooper LS, et al. Retinal arteriolar diameters and elevated blood pressure: the Atherosclerosis Risk in Communities Study. Am J Epidemiol 1999; 150:263.
  6. Wong TY, Klein R, Sharrett AR, et al. Retinal arteriolar diameter and risk for hypertension. Ann Intern Med 2004; 140:248.
  7. Wong TY, Klein R, Couper DJ, et al. Retinal microvascular abnormalities and incident stroke: the Atherosclerosis Risk in Communities Study. Lancet 2001; 358:1134.
  8. Ong YT, Wong TY, Klein R, et al. Hypertensive retinopathy and risk of stroke. Hypertension 2013; 62:706.
  9. Wong TY, Klein R, Sharrett AR, et al. Retinal arteriolar narrowing and risk of coronary heart disease in men and women. The Atherosclerosis Risk in Communities Study. JAMA 2002; 287:1153.
  10. Cheung N, Bluemke DA, Klein R, et al. Retinal arteriolar narrowing and left ventricular remodeling: the multi-ethnic study of atherosclerosis. J Am Coll Cardiol 2007; 50:48.
  11. Wong TY, Coresh J, Klein R, et al. Retinal microvascular abnormalities and renal dysfunction: the atherosclerosis risk in communities study. J Am Soc Nephrol 2004; 15:2469.
  12. Shantha GP, Kumar AA, Bhaskar E, et al. Hypertensive retinal changes, a screening tool to predict microalbuminuria in hypertensive patients: a cross-sectional study. Nephrol Dial Transplant 2010; 25:1839.
  13. Bock KD. Regression of retinal vascular changes by antihypertensive therapy. Hypertension 1984; 6:III158.
  14. Wong TY, Klein R, Islam FM, et al. Diabetic retinopathy in a multi-ethnic cohort in the United States. Am J Ophthalmol 2006; 141:446.
  15. Hsueh WA, Anderson PW. Hypertension, the endothelial cell, and the vascular complications of diabetes mellitus. Hypertension 1992; 20:253.
  16. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998; 317:703.
  17. Hyman L, Schachat AP, He Q, Leske MC. Hypertension, cardiovascular disease, and age-related macular degeneration. Age-Related Macular Degeneration Risk Factors Study Group. Arch Ophthalmol 2000; 118:351.
  18. Mitchell P, Lee AJ, Rochtchina E, Wang JJ. Open-angle glaucoma and systemic hypertension: the blue mountains eye study. J Glaucoma 2004; 13:319.
  19. Hayreh SS, Zimmerman MB, Podhajsky P, Alward WL. Nocturnal arterial hypotension and its role in optic nerve head and ocular ischemic disorders. Am J Ophthalmol 1994; 117:603.