High blood pressure is a problem plaguing millions of American adults. Many people know that controlling your blood pressure reduces your risk of heart attacks, strokes, and kidney damage, but it is less known that this can prevent eye problems from hypertensive retinopathy.

The early stages of hypertensive retinopathy, like hypertension itself, may not be noticeable. You may be diagnosed by your doctor before you notice any problems.

Uncontrolled blood pressure can cause vision loss. If you lose your sight suddenly, your blood pressure may be at very high levels and require hospitalization to control. Hypertensive retinopathy may also be progressive. Getting regular checkups and eye exams will help you monitor your condition and stay healthy.

What Is Hypertensive Retinopathy?

High blood pressure is a chronic problem that damages blood vessels all over your body and can lead to heart failure. Heart attacks, strokes, heart failure, and kidney damage are all well-known problems associated with high blood pressure, especially uncontrolled blood pressure problems. Few people associate vision loss with high blood pressure, but hypertensive retinopathy is very common.

All parts of your body contain numerous tiny blood vessels so tissues can get enough oxygen, and your eyes contain thousands of these blood vessels. Without proper blood flow, the delicate tissues in your eyes become damaged. You may develop optic nerve damage, fluid buildup under the retina, or blood vessel damage around the retina.

Retinopathy is damage to the retina from lack of blood flow. Diabetic retinopathy is a common form of this condition, but people who struggle with high blood pressure are at risk of hypertensive retinopathy. Like diabetic retinopathy, hypertensive retinopathy occurs because of damaged blood vessels around the retina, causing tissue damage to this area that, when healthy, sends light signals through the optic nerve to the brain.

Symptoms & Progression of Hypertensive Retinopathy

Hypertension causes the walls of blood vessels to thicken, which decreases how much blood can flow through them. In the eyes, reduced blood supply to the retina can cause the tissues to starve and die, leading to vision loss. Symptoms include:

  • Dim vision.
  • Double vision.
  • Slow vision loss.

Like many chronic eye diseases, you will not be able to tell if you have hypertensive retinopathy in the early stages. Symptoms are barely noticeable, if present at all. Instead, regular eye exams with dilated pupils and a slit lamp test can detect damage to your retina or changes to the blood vessels at the back of your eye.

Your optometrist or ophthalmologist will grade hypertensive retinopathy on a scale of 1 to 4.

  1. Grade 1: You have no noticeable symptoms, but some blood vessel changes. This may also be called the vasoconstrictive phase.
  2. Grade 2: Blood vessels have changed and hardened, and you have experienced a little vision loss like dim vision. Some clinicians refer to this phase as the sclerotic phase.
  3. Grade 3: Blood leaks from damaged blood vessels and is further damaging the retina. This is called the exudative phase by clinicians.
  4. Grade 4: Swelling occurs in the macula, which is the center of the retina, as well as in the optic nerve due to blood leaking from damaged blood vessels. This causes vision loss. Doctors call this malignant hypertension because it can be difficult to manage, and systemic damage can be so serious.

The amount of blood vessel damage around the retina tends to correlate with blood vessel hardening and damage in other parts of the body. If you have severe hypertensive retinopathy, it is likely you also suffer chest pain, kidney damage, and related problems.

Diagnosing Hypertensive Retinopathy

Ophthalmologists recommend conducting thorough annual eye examinations for hypertensive retinopathy to catch it early. That involves testing eye pressure, checking the back of the eye (fundoscopy), and tests for sharpness and clarity of your vision (visual acuity).

To diagnose hypertensive retinopathy, start by examining the patient’s disease history and complications, and work your way to the symptoms. Common symptoms include eye pain, headaches, blurry vision, chest pain, heart palpitations, and shortness of breath.

After that, conduct a physical examination involving lung exams, neurological/nervous system tests, and heart and blood vessels (cardiovascular) exams. Further, the ophthalmologist will check for other vital signs, and examine the back of your eye (dilated-pupil fundus examination (DFE)).

Ophthalmologists have graded retinopathy into four degrees, according to the level of damage to your retina:

  • Grade 1 may not display any symptoms
  • Grade 2-3 have accompanying swelling in the retina, and you will notice changes and leaking from the blood vessels
  • Grade 4 leads to lowered vision caused by swelling of the optic nerve and center of the retina

Examining the circulation of blood around the retina (fluorescein angiography) if you have a severe case of malignant hypertension will reveal enlargement of the venous end (microaneurysm formation), uneven drainage patterns in the wall of your eye (dendritic pattern in choroidal filling), and inefficient fluid delivery (capillary nonperfusion).

Later stages of hypertensive retinopathy show leaking of fluids.

Managing & Treating Hypertensive Retinopathy

Hypertensive retinopathy may not be preventable, but it is manageable as long as you control your blood pressure. Work with your physician to make lifestyle changes and take medication that can keep your blood pressure at a healthy level.

Keep your eye doctor up to date about your blood pressure, so they can monitor for hypertensive retinopathy. Symptoms might indicate that your blood pressure is not as well controlled as you think it is.

If you experience sudden dimming or loss of vision, you may be having a cardiac event like a heart attack or stroke. Your blood pressure could be extremely high. This is considered a medical emergency and requires immediate treatment in a hospital. Call 911.

To diagnose this condition, your eye doctor will also need to rule out conditions that look like hypertensive retinopathy, including:

  • Diabetic retinopathy.
  • Retinal venous obstruction.
  • Hyperviscosity syndrome.
  • Ocular ischemic syndrome.
  • Radiation retinopathy.

Typically, your eye doctor will look at your retina and photographs of the arteries and veins around your retina. They will assess your medical history of high blood pressure to determine whether you have hypertensive retinopathy or a different condition.

As long as your blood pressure is managed, you can heal and recover much of your sight. People who develop Grade 4 hypertensive retinopathy will have permanent vision damage, but grades before that can still recover.

Lifestyle changes to improve your blood pressure may include:

  • Eating a well-balanced, low-salt diet.
  • Limiting how much alcohol you drink.
  • Getting regular, moderate exercise.
  • Managing your stress levels.
  • Maintaining a healthy weight.

You should always take medications for your blood pressure as prescribed by your doctor. There are no other treatments for hypertensive retinopathy.

How Many People Suffer From Hypertensive Retinopathy

Among the American adult population, hypertensive retinopathy affects people of Chinese and African American descent the most. About 33% of U.S. adults have hypertension, with the condition only affecting 2% to 17% of people without diabetes.

In middle-aged adults younger than 45, hypertensive retinopathy is more prevalent among men. However, the situation flips among senior citizens. The condition affects more women than men older than 65.

A recent study found that hypertensive retinopathy affects 83% of hypertensive patients, with the highest prevalence being at earliest two of the four grades of the condition. Grade 1 has a 37% prevalence, followed by 17% at grade 2.

Researchers observed that kidney disease was the most influential factor for predicting chronic hypertensive retinopathy.

References

Health Threats From High Blood Pressure. American Heart Association.

How High Blood Pressure Can Lead to Vision Loss. American Heart Association.

High Blood Pressure and Eye Disease. (August 2018). MedlinePlus.

Hypertensive Retinopathy. (May 2019). Merck Manual: Consumer Version.

Hypertensive Retinopathy. (January 2019). StatPearls Publishing.

Changes You Can Make to Manage High Blood Pressure. American Heart Association.

Can High Blood Pressure Hurt My Eyes? (December 2020). MedicineNet.

Hypertensive Retinopathy. (May 2021). American Academy of Ophthalmology.

High Blood Pressure and Eye Disease. (August 2020). US National Library of Medicine.

Hypertensive Retinopathy. (July 2021). National Center for Biotechnology Information.

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