Hypertensive retinopathy is when high blood pressure damages the delicate blood vessels in the eyes. There are different staging or grading systems. In the early stages, the damage is slight. In the later stages, vision loss may occur.

In the United States, about 1 in 4 adults with high blood pressure have their condition under control. People with uncontrolled blood pressure are at risk of developing various health conditions, including hypertensive retinopathy.

There are four main stages of hypertensive retinopathy. People with the condition may not experience any symptoms until the later stages.

Keep reading to learn more about hypertensive retinopathy, including the different stages, diagnosis, and treatment.

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Hypertensive retinopathy is a progressive medical condition that can lead to vision loss. It happens when high blood pressure damages delicate blood vessels found in the light-sensitive tissue at the back of the eye, or retina.

The damage can cause the blood vessels to leak blood and fluid, potentially resulting in vision loss.

Because hypertensive retinopathy is a serious condition, early diagnosis and treatment are vital to preserving the individual’s eyesight.


People may not experience any symptoms until hypertensive retinopathy has progressed to a later stage. Potential symptoms include:

  • vision problems
  • headaches
  • swollen eyes
  • burst blood vessels in the eyes

If an individual has high blood pressure and they suddenly experience vision changes, they should seek emergency medical help.

New imaging techniques can determine the severity of the disease.

There are various grading systems for hypertensive retinopathy, and their intention is to correlate the condition to the severity of hypertension. Some examples include:

Keith Wagener Barker (KWB)

One classification system by Keith, Wagener, and Barker (KWB) categorizes the common signs of hypertensive retinopathy into four grades. These include:

  • Grade 1: In this grade, there is a slight narrowing of the retinal arteries.
  • Grade 2: Grade 1 plus further narrowing of the retinal arteries, doctors call this arteriovenous nicking (AV).
  • Grade 3: Grade 2 plus hemorrhaging of the retina. Also, fluffy white areas, cotton-wool spots, and hard exudates might appear. Hard exudates are plaques composed of lipids and protein materials, that leak out of the retina.
  • Grade 4: Grade 3 plus there is optical disc swelling and usually severe vision problems. The individual is also at risk for heart disease, kidney disease, and stroke.

Other classification systems

  • Scheie classification: This has two main components. These include the staging of the hypertensive retinopathy — which is similar to the KWB grades — and staging for the extent of arteriosclerosis. Arteriosclerosis refers to the state in which the walls of the arteries harden or thicken.
    • Stage 0: no abnormalities
    • Stage 1: widening of light reflex from the surface of the retina, this refers to the amount of reflected light at the center of the retina
    • Stage 2: Stage 1 plus arteriovenous crossing sign, a pattern where arterioles cross over with veins
    • Stage 3: arterioles appear as a copper wires
    • Stage 4: arterioles appear as a silver wires
  • Simplified Wong and Mitchell grading: This uses a three-grade classification system that may be easier for doctors to use.
    • Mild: includes one or more of the following signs — arteriolar narrowing, arteriovenous nicking, and copper wiring of arterioles
    • Moderate: includes one or more following signs — retinal hemorrhaging, cotton wool spots, or leaking from the retina
    • Malignant: signs from moderate retinopathy, plus optic disk swelling

The main cause of hypertensive retinopathy is high blood pressure, also called hypertension. If someone has high blood pressure, it means that when blood pumps out of the heart and into the arteries, the force of blood against the artery walls is too high.

If blood flows through the body with too much pressure, the arteries and blood vessels can stretch and become damaged over time. This leads to multiple health problems, including hypertensive retinopathy.

People may develop high blood pressure for various reasons, such as family history or obesity.

Certain factors may make an individual more likely to develop hypertensive retinopathy, including:

  • high blood pressure
  • kidney disease
  • heart disease
  • atherosclerosis
  • diabetes
  • high cholesterol
  • smoking
  • living with overweight or obesity
  • a diet high in processed foods and salt
  • alcohol misuse

Additionally, individuals of Afro-Caribbean descent, particularly women, are more at risk of developing hypertensive retinopathy.

Learn more about the risk factors for hypertension.

To diagnose hypertensive retinopathy, eye doctors, or ophthalmologists may perform routine tests, fundoscopic examination, retinal imaging, and other exams.

Doctors use an ophthalmoscope to shine light through the pupil and examine the back of the eye and retina. They check the health of the blood vessels and look for signs of narrowing or leaking fluid.

They may also use a test called fluorescein angiography to check blood flow to the retina. This involves taking images of the back of the eye, using medicated drops to widen the pupil, and a special dye called fluorescein. The doctors inject fluorescein into the arm vein.

Treatment for hypertensive retinopathy involves managing the person’s blood pressure with medications and lifestyle changes.


Medications can help lower blood pressure and reduce further damage to the eyes. Some examples are:

  • diuretics
  • beta-blockers
  • ACE inhibitors

However, if an individual has severe hypertensive retinopathy, the eye damage may be irreversible, and they may have permanent vision problems.

Lifestyle changes

A doctor may recommend that an individual makes various lifestyle changes to help them lower and maintain moderate blood pressure. Some recommendations might include:

  • quitting smoking
  • taking regular exercise
  • reducing salt intake
  • eating a balanced diet

Learn more about how a person with hypertension can manage their condition.

Adhering to these measures may help prevent the development of hypertensive retinopathy in some people.

Individuals with hypertensive retinopathy can develop complications of the retina. Some examples include:

  • Ischemic optic neuropathy: This occurs when high blood pressure interferes with normal blood flow to the eyes and damages the optic nerve. The optic nerve is responsible for carrying images to the brain.
  • Retinal artery occlusion: This occurs if arteries that carry blood to the retina become blocked with clots. This can damage the retina and potentially leads to vision loss.
  • Nerve fiber layer ischemia: This occurs when there is damage to the nerve fibers, which can then result in the appearance of cotton wool spots on the retina.

A rare, potentially life threatening complication of hypertensive retinopathy is a condition called malignant hypertension. It can occur suddenly in people and cause vision loss.

Individuals with hypertensive retinopathy also have an increased risk of stroke.

A person’s outlook can depend on the extent of the hypertensive retinopathy damage and the disease stage.

People with higher grades of hypertensive retinopathy have a reduced outlook. This is because doctors associate them with stroke, heart problems, and death.

If an individual has uncontrolled hypertension and grade 4 hypertensive retinopathy, within 2 months of diagnosis, the mortality rate is as high as 50% and increases to almost 90% by the end of the first year.

Treating hypertension can halt further retinal changes. However, if the eye becomes damaged due to hypertensive retinopathy, some changes may be irreversible even with treatment.

Hypertensive retinopathy is a progressive eye condition that can cause vision problems in people.

The condition is caused by high blood pressure, which then damages the retina’s blood vessels. Therefore, the best way to prevent hypertensive retinopathy is to maintain healthy blood pressure and have regular blood pressure checks.