Grade III or Grade IV Hypertensive Retinopathy with Severely Elevated Blood Pressure

Abstract

Introduction: Hypertensive retinopathy describes a spectrum of retinal changes in patients with elevated blood pressure (BP). It is unknown why some patients are more likely to develop acute ocular end-organ damage than others with similar BP. We examined risk factors for grade III/IV hypertensive retinopathy among patients with hypertensive urgency in the emergency department (ED) and compared healthcare utilization and mortality between patients with and without grade III/IV hypertensive retinopathy.

Methods: A preplanned subanalysis of patients who presented to a university hospital ED with diastolic BP ≥ 120 mmHg and who enrolled in the Fundus Photography versus Ophthalmoscopy Trial Outcomes in the ED study was performed. Bilateral nonmydriatic ocular fundus photographs, vital signs, and demographics were obtained at presentation. Past medical history, laboratory values, healthcare utilization, and mortality were ascertained from medical record review at least 8 months after initial ED visit.

Results: Twenty-one patients with diastolic BP ≥ 120 mmHg, 7 of whom (33%) had grade III/IV hypertensive retinopathy, were included. Patients with retinopathy were significantly younger than those without (median 33 vs 50 years, P= 0.02). Mean arterial pressure (165 vs 163 mmHg) was essentially equal in the 2 groups. Patients with retinopathy had substantially increased but nonsignificant rates of ED revisit (57% vs 29%, P = 0.35) and hospital admission after ED discharge (43% vs 14%, P = 0.28). One of the patients with retinopathy died, but none without.

Conclusion: Younger patients may be at higher risk for grade III/IV hypertensive retinopathy among patients with hypertensive urgency. Chronic compensatory mechanisms may have not yet developed in these younger patients. Alternatively, older patients with retinopathy may be underrepresented secondary to increased mortality among these patients at a younger age (survivorship bias). Further research is needed to validate these preliminary findings.

Figure 1.

Normal versus grade I/II hypertensive retinopathy. (Top) Normal ocular fundus. Note that the ratio between the arteries and the veins (arteriovenous [AV] ratio) is about 2:3. (Middle) Grade I hypertensive retinopathy. Note mild narrowing and sclerosis of retinal arteries with an overall AV ratio of about 1:2. (Bottom) Grade II hypertensive retinopathy. There is AV nicking (arrow) and moderate to severe narrowing and sclerosis of arterioles (eg, within the ellipse the AV ratio is less than 1:2).

Figure 2.

Examples of grade III/IV hypertensive retinopathy. Note the features of grade III retinopathy: exudates (asterisks), cotton wool spots (arrows), and nerve fiber layer hemorrhages (ellipses). Grade IV hypertensive retinopathy is defined by the presence of features of grade III retinopathy plus optic nerve head edema (eg, the middle right panel).