Retina Note · Hypertensive Retinopathy
Hypertensive Retinopathy Classifications
Four grading systems describe many of the same fundus findings—but they organise them for different purposes. This companion note compares their logic, stages and clinical significance without mixing the systems.
- Modified Scheie
- Scheie Arteriolar Sclerosis
- Keith–Wagener–Barker
- Wong–Mitchell
Companion note: Compare the four grading systems and learn how to recognise their different organising principles without mixing their stages.
Know the Fundus Signs First
These classifications assume familiarity with the fundus findings used to define their grades and categories:
- Generalised and focal arteriolar narrowing
- Broadening of the arteriolar light reflex
- Arteriovenous crossing changes
- Copper and silver wiring
- Retinal haemorrhages
- Cotton-wool spots
- Hard exudates
- Optic disc swelling
Review these findings in Hypertensive Retinopathy: Signs and Pathology before learning the grading systems.
Four Systems, Four Purposes
The same fundus sign may appear in more than one classification. The key is to first identify what each system is designed to grade.
-
1 Modified Scheie
Grades predominantly hypertensive retinal change, progressing from arteriolar narrowing to retinal injury and optic disc swelling.
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2 Scheie Arteriolar Sclerosis
Grades chronic arteriolar wall sclerosis, from broadening of the light reflex to copper and silver wiring.
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3 Keith–Wagener–Barker
Combines hypertensive and arteriosclerotic changes with haemorrhagic and exudative retinal findings in one four-grade system.
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4 Wong–Mitchell
Regroups retinal signs according to their systemic-risk associations and clinical significance.
Modified Scheie: Hypertensive Change Hypertensive Change
The hypertensive component of the Scheie system grades the retinal response to elevated blood pressure. It progresses from arteriolar narrowing to retinal tissue injury and finally optic disc swelling. [1]
| Grade | Retinal findings |
|---|---|
| Grade 0 | No detectable hypertensive retinal change. |
| Grade 1 | Barely detectable generalized arteriolar narrowing. |
| Grade 2 | More obvious arteriolar narrowing with focal irregularities. |
| Grade 3 |
Grade 2 vascular changes with
one or more signs of retinal injury:
|
| Grade 4 | Grade 3 changes with optic disc swelling. |
Scheie: Arteriolar Sclerosis Arteriolar Sclerosis
Scheie separately graded the chronic sclerotic changes of the retinal arteriolar wall. As the wall becomes thicker and more opaque, the central light reflex broadens and progresses towards copper and silver wiring. [1]
| Grade | Arteriolar finding |
|---|---|
| Grade 0 | No visible retinal arteriolar sclerosis. |
| Grade 1 | Slight broadening of the arteriolar light reflex. |
| Grade 2 | More prominent broadening of the light reflex with arteriovenous crossing changes. |
| Grade 3 | Copper wiring. The blood column remains partly visible through the increasingly opaque arteriolar wall. |
| Grade 4 | Silver wiring. Advanced wall opacity largely obscures the underlying blood column. |
Keith–Wagener–Barker: Combined Grading Keith–Wagener– Barker: Combined Grading
The Keith–Wagener–Barker classification combines vasoconstrictive, arteriosclerotic, haemorrhagic and exudative fundus findings within one four-grade system. [2] [4]
| Grade | Fundus findings |
|---|---|
| Grade 1 | Mild generalized narrowing of the retinal arterioles. |
| Grade 2 |
More definite generalized or focal arteriolar narrowing with:
|
| Grade 3 |
Grade 2 changes with
one or more signs of retinal injury:
|
| Grade 4 | Grade 3 changes with optic disc swelling. |
Clinical Update
This remains a classic examination classification, but its early grades can be subjective because hypertensive narrowing and chronic arteriosclerotic change are combined within the same system. [4]
Wong–Mitchell Classification
Wong and Mitchell proposed a simplified clinical classification that groups hypertensive retinopathy into four categories and relates the retinal findings to systemic vascular risk. [3]
| Category | Retinal findings and systemic association |
|---|---|
| None |
Retinal findings
No detectable signs of hypertensive retinopathy. |
| Mild |
Retinal findings
One or more signs of retinal arteriolar change:
Systemic association
Modest association with clinical stroke, subclinical stroke, coronary heart disease and mortality. |
| Moderate |
Retinal findings
One or more signs of retinal tissue injury:
Systemic association
Strong association with clinical and subclinical stroke, cognitive decline and cardiovascular mortality. |
| Malignant |
Retinal findings
Moderate hypertensive retinopathy with optic disc swelling.
Systemic association
Strong association with mortality. |
Modest association: reported odds ratio greater than 1 but less than 2.
Strong association: reported odds ratio of 2 or greater.
Do Not Mix the Systems
The classifications overlap in their fundus findings, but each is built around a different organising principle. [1] [2] [3] [4]
| Classification | Based on | Earlier pattern | Advanced pattern |
|---|---|---|---|
| Modified Scheie | Hypertensive retinal change | Arteriolar narrowing and focal irregularity | Retinal injury followed by optic disc swelling |
| Scheie Arteriolar Sclerosis | Chronic arteriolar wall sclerosis | Broadening of the arteriolar light reflex | Copper wiring followed by silver wiring |
| Keith–Wagener–Barker | Hypertensive and sclerotic findings combined | Narrowing, crossing changes and increased light reflex | Retinal injury followed by optic disc swelling |
| Wong–Mitchell | Systemic-risk association | Mild vascular signs with a modest association | Moderate retinal injury or malignant retinopathy with optic disc swelling |
References
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Scheie HG. Evaluation of ophthalmoscopic changes of hypertension and arteriolar sclerosis. AMA Arch Ophthalmol. 1953;49(2):117–138. doi:10.1001/archopht.1953.00920020122001
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Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: their course and prognosis. Am J Med Sci. 1939;197:332–343. doi:10.1097/00000441-193903000-00006
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Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004;351(22):2310–2317. doi:10.1056/NEJMra032865
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Wong TY, Mitchell P. The eye in hypertension. Lancet. 2007;369(9559):425–435. doi:10.1016/S0140-6736(07)60198-6
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Reier L, Fowler JB, Arshad M, et al. Optic disc edema and elevated intracranial pressure: a comprehensive review of papilledema. Cureus. 2022;14(5):e24915. doi:10.7759/cureus.24915
