A grade 3 hypertensive retinopathy
A grade 4 hypertensive retinopathy showing
disc oedema and hard exudate at the macula
Nowadays it is uncommon to encounter malignant hypertension due to good screening programme and effective
treatment for high blood pressure. However, you must be able to recognize the features of hypertensive retinopathy
especially that of malignant hypertension. Early hypertensive retinopathy (grade 1 and 2) are commonly seen in the
presence of other retinal conditions such as branch retinal vein occlusion, branch retinal artery occlusion or
In the examination, if the main focus is on hypertensive retinopathy the patient usually has grade 3 or 4 hypertensive
retinopathy. In grade 3: there are retinal arterioles narrowing with artero-venous nipping. The retina contains
flame-shaped and blot haemorrhages, cotton-wool spots and hard exudates in the macula which may be star-shaped.
In grade 4: features of grade 3 plus papilloedema.
1. How can hypertension affect the eye?