Hypertensive Retinopathy

Abstract

At the end of the 19th century, hypertensive retinopathy was first described by Markus Gunn in hypertensive patients with renal disease. Nearly 50 years later, Keith and colleagues documented the prognostic value of funduscopic abnormalities in hypertensive patients and categorized hypertensive nephropathy into 4 groups of increasing severity that since then have been taught in medical university schools. In 1966, the ophthalmoscopic changes were confirmed to be predictive of death in patients with essential hypertension.1,2 The usefulness of the classification system and its relevance to current clinical practice, however, have been questioned repeatedly.3 The direct ophthalmoscopic examination has been shown to be unreliable, with high rates of interobserver (20% to 40%) and intraobserver (10% to 33%) variability.4 The criticism refers to stages 1 and 2 of the Keith-Wagner-Barker classification. Only hemorrhages and exudates can be reliably assessed in retinal photographs. A systematic review identified 6 studies that provided data on interobserver agreement for hypertensive retinopathy using retinal photographs.3 In these studies interobserver agreement was modest and fair for focal arterial narrowing and arteriovenous nicking, good for the arteriovenous ratio, and excellent only for hemorrhages and exudates. Most current guidelines for the management of arterial hypertension, therefore, do not recommend funduscopy as a routine diagnostic test, but advanced retinopathy (hemorrhages, exudates, or papilledema) is accepted as a factor influencing prognosis in hypertensive patients.5 Hypertensive retinopathy is generally considered to be a marker and/or …