Video companion note

Hypertensive Retinopathy
Signs and Pathology

A concise, examination-aware guide to recognising the ocular signs of systemic hypertension and understanding the vascular pathology behind them — across the retina, choroid, and optic nerve head.

  • Intermediate level
  • Fundus signs
  • Clinical pathology
Clinical anchor: systemic hypertension can affect three posterior-segment sites — retina, choroid, and optic nerve head.

not just the retinal vessels

1

Retina

Hypertensive retinopathy

2

Choroid

Hypertensive choroidopathy

3

Optic nerve head

Disc edema in severe disease

Watch the Lecture

Focus while watching: connect each fundus sign to its vascular mechanism — retinal arteriolar narrowing, choroidal compromise, or optic nerve-head involvement.

Core framework

What Hypertension Does to Each Site

Hypertension affects the eye through vascular stress, vasoconstriction, endothelial injury, ischemia, and leakage. The key is to localise the sign to the retina, choroid, or optic nerve head. [1,2]

  • Retina

    Arteriolar narrowing, arteriolar sclerosis, hemorrhages, cotton-wool spots, and hard exudates.

  • Choroid

    Acute severe hypertension can compromise choroidal circulation and injure the RPE–outer retina complex.

  • Optic nerve head

    Severe hypertension may produce optic disc edema with surrounding hemorrhages, cotton-wool spots, and macular star pattern.

Scope note Retinal vascular occlusions are also associated with hypertension, but CRAO, BRAO, CRVO, and BRVO are separate topics. [2]
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Retinal roadmap

Three Sign-Patterns

For fundus reading, group hypertensive retinopathy into three practical patterns. This is only a roadmap — the detailed signs are explained in the sections below. [1]

  • Vasoconstrictive

    Generalised or focal arteriolar narrowing.

  • Arteriolosclerotic

    Copper wiring, silver wiring, and AV crossing signs.

  • Exudative / ischemic

    Hemorrhages, cotton-wool spots, hard exudates, and macular star.

Wisdom Pearl These patterns are not a strict timeline. A real fundus may show more than one pattern at the same time.

use this as a map, not a staging system

Vasoconstrictive pattern

Arteriolar Narrowing

An acute rise in blood pressure can trigger retinal arteriolar vasoconstriction through autoregulation. Clinically, this is read as narrowing of the retinal arterioles. [1]

  • Generalised narrowing

    The retinal arterioles look diffusely narrow compared with the venules.

  • Focal narrowing

    A short segment of an arteriole appears locally constricted.

Caveat The arteriole-to-venule calibre ratio is often taught as approximately 2:3, but it should be used as a clinical estimate, not as a rigid measurement in every fundus photograph.

estimate the calibre — don’t over-measure it

Arteriolosclerotic pattern

Copper, Silver and AV Signs

With chronic hypertension, retinal arterioles may develop wall thickening and arteriolosclerotic change. This alters the vessel reflex and may affect the adjacent vein at crossings. [1,3]

  • Copper wiring

    Bright yellow-orange arteriolar reflex with partial visibility of the blood column.

  • Silver wiring

    Pale or whitish arteriolar reflex with marked obscuration of the blood column.

  • AV crossing signs

    Venous distortion at an arteriovenous crossing. The classical signs are detailed in the next section.

Clinical Pearl Copper wiring, silver wiring, and AV crossing signs point to chronic retinal arteriolar sclerosis. Alone, they do not prove acute severe hypertension.

AV crossing signs

Classical AV Crossing Signs

At an arteriovenous crossing, a thickened arteriole can compress or distort the adjacent vein. The classical signs describe what happens to the vein at that crossing. [3,4]

  • Salus sign

    Classical description

    Deflection of the vein at the AV crossing.

    Simple recall

    The vein changes direction.

  • Gunn sign / AV nicking

    Classical description

    Tapering or narrowing of the vein at the crossing.

    Simple recall

    The vein is pinched.

  • Bonnet sign

    Classical description

    Dilatation or banking distal to the crossing.

    Simple recall

    The vein backs up beyond the crossing.

Caveat These signs are useful for examination description, but they should be interpreted with the full retinal picture and systemic context.

in viva, describe the vein — deflected, pinched, or banked

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Exudative / ischemic pattern

Hemorrhages and Exudative Signs

More severe vascular injury causes endothelial damage, blood-retinal barrier breakdown, and retinal nerve-fiber-layer ischemia. [1,2]

  • Hemorrhages

    Flame-shaped hemorrhages are superficial; dot-blot hemorrhages are deeper intraretinal hemorrhages.

  • Cotton-wool spots

    Focal retinal nerve-fiber-layer ischemia with impaired axoplasmic flow.

  • Hard exudates

    Lipid-rich deposits from vascular leakage; around the macula, they may form a macular star.

Clinical Pearl This pattern suggests more severe vascular injury than narrowing or chronic arteriolosclerotic signs alone. [2,4]

Do not confuse

Cotton-Wool Spots vs Hard Exudates

Both can appear as pale retinal lesions, but they represent different pathology: cotton-wool spots are ischemic, while hard exudates are leakage-related. [1,2]

  • Cotton-wool spots

    Soft, fluffy white retinal nerve-fiber-layer lesions caused by focal ischemia and impaired axoplasmic flow.

  • Hard exudates

    Sharply defined yellow lipid-rich deposits caused by vascular leakage; around the macula, they may form a macular star.

Clinical shortcut: cotton-wool spot = ischemia. Hard exudate = leakage.

fluffy white = ischemia; sharp yellow = leakage

Choroidal involvement

Hypertensive Choroidopathy

Hypertensive choroidopathy is a major ocular manifestation of acute severe or malignant hypertension. It is not just an add-on to retinopathy. [5,6]

  • 1

    Severe hypertension injures choroidal arterioles.

  • 2

    This can produce fibrinoid necrosis and patchy choriocapillaris non-perfusion.

  • 3

    The overlying RPE and outer retina become ischemic or dysfunctional.

Clinical anchor: retinopathy means retinal vascular injury. Choroidopathy means choroidal vascular compromise with RPE–outer retinal involvement.

when the choroid is involved, think acute severe hypertension

Choroidal sign

Elschnig Spots

Elschnig spots are focal lesions produced by choroidal ischemia with overlying RPE damage. They are important because they shift your thinking from simple retinal arteriolar disease to choroidal involvement. [5,6]

  • Acute Elschnig spot

    Pale or yellowish lesion at the RPE level.

  • Healed Elschnig spot

    Pigmented spot, often with a surrounding hypopigmented halo.

Clinical clue: Elschnig spots suggest that the choroidal circulation is involved — not only the retinal arterioles.

RPE-level lesion = think choroid

Choroidal sign

Siegrist Streaks

Siegrist streaks are linear hyperpigmented streaks that follow choroidal arteries. They point to choroidal vascular injury in severe hypertensive disease. [5,7]

  • Appearance

    Linear hyperpigmented streaks, usually tracking along the course of choroidal arteries.

  • Pathology

    Choroidal vascular injury related to severe hypertension.

  • Clinical meaning

    A warning sign that the disease process is not limited to retinal arterioles.

Do not overcomplicate: Elschnig spots are focal RPE-level lesions; Siegrist streaks are linear streaks along choroidal arteries.

focal spot vs linear streak

Choroidal complication

PED and Serous RD

In severe hypertensive choroidopathy, RPE barrier and pump dysfunction can allow fluid to collect under the RPE or neurosensory retina. [7,8]

  • PED

    Fluid accumulates beneath the retinal pigment epithelium.

  • Serous RD

    Subretinal fluid produces an exudative, or serous, retinal detachment.

  • Clinical setting

    It may be bilateral and is especially important in pregnancy-related hypertension. [7,8]

Clinical Pearl In this context, serous fluid is a choroid–RPE problem, not a primary retinal tear problem.
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Systemic context

When Choroidopathy Matters

Hypertensive choroidopathy is especially important when the blood pressure rise is severe, acute, or systemic-disease related. [5,7]

  • Malignant hypertension

    Choroidal ischemic signs may accompany severe retinal and optic nerve-head involvement.

  • Renal disease

    Severe hypertension related to renal disease can present with choroidal involvement.

  • Pheochromocytoma

    Sudden or severe hypertensive episodes may produce marked ocular vascular injury.

  • Pre-eclampsia / eclampsia

    Pregnancy-related hypertension is a classic setting where choroidopathy and serous detachment must not be missed.

Important These fundus signs should prompt systemic assessment, not only an eye diagnosis.

the eye may be the clue to severe systemic vascular disease

Optic nerve head involvement

Optic Disc Edema in Severe Hypertension

The optic nerve head is the third posterior-segment site affected by severe hypertension. The term hypertensive optic neuropathy is usually reserved for severe cases with optic disc edema. [9,10]

  • Disc appearance

    Blurred disc margins and a swollen optic nerve head.

  • Peripapillary signs

    Flame-shaped hemorrhages, cotton-wool spots, and vascular congestion around the disc.

  • Macular pattern

    Hard exudates may arrange radially to form a macular star.

Mechanism: severe hypertensive vascular injury at the optic nerve head can cause ischemia, leakage, and impaired axoplasmic flow. [1,9]

severe hypertension can involve the disc, not only the retina

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Differential clue

Disc Edema vs Papilledema

Both can produce a swollen optic disc. The distinction comes from the clinical setting, the associated fundus signs, and the symptom pattern. [9,10]

  • Primary driver

    Hypertensive disc edema: severe systemic hypertension.
    Papilledema: raised intracranial pressure.

  • Fundus company

    Hypertensive pattern: severe retinopathy or choroidopathy may coexist — hemorrhages, cotton-wool spots, hard exudates, macular star, Elschnig spots, or serous RD.
    ICP pattern: disc swelling is interpreted mainly in an intracranial-pressure context.

  • Systemic clue

    Hypertensive pattern: very high BP, renal disease, pregnancy-related hypertension, or acute target-organ concern.
    ICP pattern: headache, transient visual obscurations, pulsatile tinnitus, diplopia, or sixth-nerve palsy.

Do Not Confuse Do not separate them by disc appearance alone. Use the whole patient, not the disc margin alone.

hypertensive story plus retinal/choroidal signs vs ICP story

Note Severe hypertensive retinopathy, hypertensive choroidopathy, or optic disc edema should prompt urgent systemic assessment for acute target-organ damage. Very high BP without acute target-organ damage is not the same as hypertensive emergency; hypertensive emergency means severe BP elevation with acute hypertension-mediated organ damage. [12]

One-minute summary

What to Remember

Hypertension can affect the retina, choroid, and optic nerve head. Localise the sign first, then connect it to the vascular process underneath. [1,5,9]

  • Retina

    Narrowing, sclerosis, hemorrhages, cotton-wool spots, hard exudates, and macular star.

  • Choroid

    Elschnig spots, Siegrist streaks, PED, and serous RD point to choroidal–RPE involvement.

  • Optic nerve head

    Severe hypertension may produce optic disc edema with surrounding retinal signs.

  • Systemic action

    Severe retinopathy, choroidopathy, or disc edema should trigger urgent systemic assessment. [12]

Final Anchor Retina = retinal vascular injury. Choroid = choroidal–RPE ischemic injury. Optic nerve head = disc edema in severe hypertension.

localise first: retina, choroid, or disc

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References

  1. Tso MOM, Jampol LM. Pathophysiology of hypertensive retinopathy. Ophthalmology. 1982;89(10):1132–1145. doi:10.1016/S0161-6420(82)34663-1.
  2. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004;351(22):2310–2317. doi:10.1056/NEJMra032865.
  3. Grosso A, Veglio F, Porta M, Grignolo FM, Wong TY. Hypertensive retinopathy revisited: some answers, more questions. Br J Ophthalmol. 2005;89(12):1646–1654. doi:10.1136/bjo.2005.072546.
  4. Tsukikawa M, Stacey AW. A review of hypertensive retinopathy and chorioretinopathy. Clin Optom. 2020;12:67–73. doi:10.2147/OPTO.S183492.
  5. Hayreh SS, Servais GE, Virdi PS. Fundus lesions in malignant hypertension. VI. Hypertensive choroidopathy. Ophthalmology. 1986;93(11):1383–1400. doi:10.1016/S0161-6420(86)33554-1.
  6. Kishi S, Tso MOM, Hayreh SS. Fundus lesions in malignant hypertension. I. A pathologic study of experimental hypertensive choroidopathy. Arch Ophthalmol. 1985;103(8):1189–1197. doi:10.1001/archopht.1985.01050080101029.
  7. Bourke K, Patel MR, Prisant LM, Marcus DM. Hypertensive choroidopathy. J Clin Hypertens. 2004;6(8):471–472. doi:10.1111/j.1524-6175.2004.3749.x.
  8. Ahn SJ, Woo SJ, Park KH. Retinal and choroidal changes with severe hypertension and their association with visual outcome. Invest Ophthalmol Vis Sci. 2014;55(12):7775–7785. doi:10.1167/iovs.14-14915.
  9. Hayreh SS, Servais GE, Virdi PS. Fundus lesions in malignant hypertension. V. Hypertensive optic neuropathy. Ophthalmology. 1986;93(1):74–87. doi:10.1016/S0161-6420(86)33773-4.
  10. Hayreh SS. Systemic arterial blood pressure and the eye. Eye. 1996;10:5–28. doi:10.1038/eye.1996.3.
  11. Jones DW, Ferdinand KC, Taler SJ, Johnson HM, Shimbo D, Abdalla M, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Circulation. 2025;152(11):e114–e218. doi:10.1161/CIR.0000000000001356.
  12. McEvoy JW, McCarthy CP, Bruno RM, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024;45(38):3912–4018. doi:10.1093/eurheartj/ehae178.

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