# Hypertensive (arteriosclerotic) retinopathy - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Hypertensive Retinopathy - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK525980/ · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class FD67.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care - Verified date: 2026-08 ## Verified against - No dose - referral pathway, no medicine given in primary care ## Treatment metadata - No drug therapy in primary care (Referral & Advice) ## Complete treatment card ```text HYPERTENSIVE (ARTERIOSCLEROTIC) RETINOPATHY Sources: Hypertensive Retinopathy - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK525980/ · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class FD67.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care Review status: REVIEWED against the source listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (2) - Malignant hypertension can present with headaches or a decline in vision in both eyes [hypertension] - The retinal finding is more often picked up incidentally on a routine eye exam than through symptoms SIGNS - what you find (11) - The Salus sign is a vein deflecting where it crosses an arteriole, giving a vertical hump or an S-shaped bend - The Gunn sign is tapering of the vein on either side of an AV crossing from arterial compression - The Bonnet sign is banking or widening of the vein just past the crossing point, which can precede a branch vein occlusion - The artery-to-vein width ratio can narrow from the normal 2:3 down to as low as 1:3 - Early arteriolar sclerosis widens and brightens the vessel's central light reflex, giving a burnished copper appearance (copper wiring) - In advanced sclerosis, the vessel wall becomes so opaque the artery looks like a white cord despite blood still flowing through it (silver wiring) - Bleeding in the deep retina shows as dot-blot hemorrhages, while bleeding in the superficial nerve fiber layer shows as flame-shaped hemorrhages [bleeding] - Cotton wool spots are soft exudates from nerve fiber ischemia, distinct from hard exudates, which are lipid deposits [ischaemia] - A macular star from hard exudate deposits becomes more visible once the surrounding fluid resolves [rash] - Papilledema with blurred disc margins and radial flame hemorrhages around the disc defines the malignant form - AV nicking can be a clue to long-standing hypertension even when the current blood pressure reading is normal [hypertension] TESTS (7) - The diagnosis is made by direct visualization of the retina during a dilated fundus exam - The Keith-Wagener-Barker system's group 4 adds papilledema on top of the group 3 hemorrhage and exudate findings - The Scheie system grades acute retinopathy changes and chronic arteriolosclerosis on two separate scales - OCT can show subretinal fluid at the fovea, usually continuous with swelling around the optic disc, in the malignant form - Fluorescein angiography can show microaneurysms, capillary dropout, leaky vessels, and sometimes new vessel growth - Because of the risk of kidney involvement, a nephrology referral is considered essential - Repeated blood pressure measurement, and in younger patients a work-up for a secondary cause such as kidney disease, are part of the systemic evaluation IF NOT THIS - what else fits (4) - Idiopathic intracranial hypertension, anterior ischemic optic neuropathy, and optic neuritis can also cause disc swelling and enter the differential - Central retinal vein occlusion, diabetic papillopathy, neuroretinitis, radiation papillopathy, and a retrobulbar tumor are other causes of disc swelling to rule out - Diabetic retinopathy and retinal vein obstruction can mimic the chronic form of this condition - Hyperviscosity syndrome, ocular ischemic syndrome, radiation retinopathy, and anemia or other blood disorders can also mimic the chronic changes Source StatPearls "Hypertensive Retinopathy" - disease-level clinical article Status traced to the source above 1. NO DRUG THERAPY IN PRIMARY CARE (REFERRAL & ADVICE) [1st line] Adult Retinal changes from long-standing or poorly controlled hypertension; hypertension is extremely common in Egyptian primary care. The GP's actionable step is tightening blood pressure control (handled under the existing hypertension condition) and referring to ophthalmology for grading and monitoring of the retinal findings themselves. - Refer, with advice Peds Children follow the same pathway: recognise and refer. No primary-care medicine is implied. Source No dose - referral pathway, no medicine given in primary care Why Retinal changes from long-standing or poorly controlled hypertension; hypertension is extremely common in Egyptian primary care. The GP's actionable step is tightening blood pressure control (handled under the existing hypertension condition) and referring to ophthalmology for grading and monitoring of the retinal findings themselves. Caution No medicine is prescribed for this in primary care - this entry is for recognition and referral. Anything given is decided by the service it is referred to. RED FLAG - Severity-graded urgency is not captured: severe hypertensive retinopathy carries a strong association with mortality and needs urgent intervention and referral, not the same routine ophthalmology pathway as mild/incidental findings. RED FLAG - In severe/malignant hypertensive retinopathy, blood pressure must be lowered gradually and in a controlled manner (MAP down 10-15% in the first hour, no more than 25% in 24 hours) - rapid correction risks ischemic injury to the optic nerve, brain, and kidneys, so a blanket 'tighten BP control' is not enough. RED FLAG - Severely elevated blood pressure with visual symptoms (accelerated/malignant hypertension), papilledema, or sudden vision change. 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