25.1 Features
25.1.1 Common Symptoms
Ocular
Range from asymptomatic to decreased visual acuity and scotoma typically related to the location and extent of hypertensive retinopathy changes.
Systemic
Headache, neurologic deficits, chest pain, respiratory distress, mental status change, nausea, and/or vomiting warrant expedited treatment to reduce mortality and morbidity of hypertensive emergency and other end organ damage.
25.1.2 Exam Findings
Findings on ophthalmoscopy of hypertensive retinopathy in the early phase can include focal intraretinal periarteriolar transudates, cotton wool spots, exudates, retinal hemorrhages, and macular edema (▶ Fig. 25.1). Later and more chronic hypertensive changes include hard exudates, arteriolar attenuation, arteriovenous nicking (▶ Fig. 25.2), arteriolar copper-wiring or silver-wiring (▶ Fig. 25.2), microaneurysms, intraretinal microvascular abnormalities, and macroaneurysms. Rarely, more severe findings may include retinal neovascularization and multilayered retinal hemorrhages (▶ Fig. 25.3). There may be superimposed hypertensive choroidopathy (▶ Fig. 25.4) which can manifest as serous retinal detachments or pigmented lesions along choroidal vessels indicative of fibrinoid necrosis (Siegrist streaks). Evidence of prior acute hypertensive retinopathy episodes includes atrophy from focal choroidal infarcts (i.e., Elschnig spots, ▶ Fig. 25.4). Hypertensive optic neuropathy can manifest acutely as optic disc edema and chronically as optic atrophy.
Fig. 25.1 Acute hypertensive emergency demonstrating extensive cotton wool spots, retinal exudates/macular star formation, optic disc edema, macular edema, optic disc pallor, and retinal hemorrhages. (Courtesy of Ang Li, Alex Yuan and Jonathan Sears.)
Fig. 25.2 Chronic hypertensive retinopathy demonstrating arteriovenous nicking and early copper wiring.
Fig. 25.3 Severe acute hypertensive emergency with underlying severe chronic retinal vascular changes including neovascularization. Extensive preretinal and subretinal hemorrhage is present. Cotton wool spots and macular exudates are present.
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