Elsevier

The Lancet

Volume 369, Issue 9559, 3–9 February 2007, Pages 425-435
The Lancet

Review
The eye in hypertension

https://doi.org/10.1016/S0140-6736(07)60198-6Get rights and content

Summary

Hypertension has a range of effects on the eye. Hypertensive retinopathy refers to retinal microvascular signs that develop in response to raised blood pressure. Signs of hypertensive retinopathy are frequently seen in adults 40 years and older, and are predictive of incident stroke, congestive heart failure, and cardiovascular mortality—independently of traditional risk factors. Hypertension is also a major risk factor for the development of other retinal vascular diseases, such as retinal vein and artery occlusion, and ischaemic optic neuropathy. High blood pressure increases the risk of both development of diabetic retinopathy and its progression. Adequate control of blood pressure has been proven in randomised clinical trials to reduce vision loss associated with diabetic retinopathy. Finally, hypertension has been implicated in the pathogenesis of glaucoma and age-related macular degeneration. Recognition of the ocular effects of blood pressure could allow physicians to better manage patients with hypertension, and to monitor its end-organ effects.

Section snippets

Direct ocular effects of hypertension

Hypertensive retinopathy refers to retinal microvascular signs that are related to raised blood pressure.1 The underlying pathophysiology of these signs can be divided into stages.2 The initial response of the retinal circulation to a rise in blood pressure is vasospasm and an increase in vasomotor tone, which is seen clinically as generalised retinal–arteriolar narrowing. Subsequently, chronic arteriosclerotic changes, such as intimal thickening, media-wall hyperplasia, and hyaline

Retinal vein occlusion

Hypertension predisposes patients to development of retinal vein occlusion, a common, sight-threatening retinal–vascular disorder.42, 43, 44, 45 Retinal vein occlusion is characterised clinically by dilatated and tortuous retinal veins and the presence of retinal haemorrhages, cotton-wool spots, and oedema of the macula and optic disc. These features are seen either in all four quadrants (central retinal vein occlusion; figure 3A), or in only one (branch retinal vein occlusion; figure 3B).

Age-related macular degeneration

Age-related macular degeneration is the most common cause of visual impairment in patients aged 65 years and older in developed countries.93 Visual loss from age-related macular degeneration typically results from either neovascularisation associated with choroidal vessels (commonly termed wet or exudative age-related macular degeneration) or geographic atrophy of the retina.

Some have suggested that hypertension could increase the potential risk factor for age-related macular degeneration, on

Future directions and conclusions

Hypertension affects a large proportion of the adult population worldwide, and has widespread effects on the eye. We argue that any patient with hypertension should have an ophthalmological assessment to detect hypertensive retinopathy or other retinal vascular complications. Individuals with moderate hypertensive retinopathy (eg, flame-shaped or blot-shaped haemorrhages, cotton wool spots, hard exudates, microaneurysms, or a combination of these) are at increased risk of cardiovascular

Search strategy and selection criteria

We searched MEDLINE using PubMed with the search terms “systemic hypertension” and “blood pressure”, in combination with “eye”, “retinopathy”, “retinal arteriolar disease”, “arterio-venous nipping”, “retinal vein occlusion”, “retinal artery occlusion”, “retinal emboli”, “retinal macroaneurysm”, “ischaemic optic neuropathy”, “diabetes”, “glaucoma”, and “age-related macular degeneration”. We largely selected publications in the past 5 years, but did not exclude older publications that are

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