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Ocular effects of hypertension

Raymond R Townsend, MD
Section Editor
George L Bakris, MD
Deputy Editors
Daniel J Sullivan, MD, MPH
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).

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Literature review current through: Dec 2017. | This topic last updated: Nov 22, 2017.
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