Hypertensive Retinopathy: Grading and Hypertensive Emergencies
Last updated: November 2026
The retina is the only place where we can see small arteries directly, and hypertension changes them in a predictable sequence. Most findings are chronic and need a physician; a few signal a hypertensive emergency that needs the same-day attention of a medical team.
Grading
| Wong–Mitchell (2004) | Signs | Meaning |
|---|---|---|
| None | No detectable signs | Low risk |
| Mild | Generalised or focal arteriolar narrowing, AV nicking, opacity of the arteriolar wall (copper or silver wiring) | Modest association with stroke and heart disease |
| Moderate | Haemorrhages (blot, dot, flame), microaneurysms, cotton wool spots, hard exudates | Strong association with stroke, cognitive decline and cardiovascular death |
| Malignant (accelerated) | Moderate signs plus optic disc swelling | Hypertensive emergency: refer to the medical team the same day |
The older Keith–Wagener–Barker classification (grades 1 to 4) is still asked in exams: grade 1 mild narrowing; grade 2 marked narrowing with AV nicking; grade 3 plus haemorrhages, exudates and cotton wool spots; grade 4 plus disc swelling.
Choroid and optic nerve
- Hypertensive choroidopathy in acute severe hypertension (pre-eclampsia, phaeochromocytoma, renal crisis): Elschnig spots (yellow, later pigmented patches), Siegrist streaks along choroidal vessels, and serous retinal detachment.
- Hypertensive optic neuropathy: bilateral disc swelling with a macular star; distinguish from papilloedema by the blood pressure.
In the clinic
- Measure blood pressure in every patient with haemorrhages, cotton wool spots, vein occlusion or disc swelling.
- BP of 180/120 mmHg or more with disc swelling or new organ damage is a hypertensive emergency: refer immediately. Blood pressure should be lowered in a controlled way by the medical team; very rapid lowering can cause optic nerve and brain ischaemia.
- Associated conditions: retinal vein and artery occlusion, macroaneurysm, NAION.
Where residents slip
- Calling bilateral disc swelling papilloedema without measuring the blood pressure.
- Forgetting pre-eclampsia in a pregnant woman with serous retinal detachment.
- Advising rapid BP reduction from the eye clinic.
Test yourself: flip cards
Related: Retinal Vein Occlusion, Papilledema vs Pseudopapilledema, Medical Fitness Before Eye Surgery: BP, Sugar, Tamsulosin, GLP-1 and SGLT2.
Key sources
- Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004;351:2310-2317
- Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: their course and prognosis. Am J Med Sci. 1939;197:332-343
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