## Hypertensive Retinopathy: Clinical Features **Key Point:** Hypertensive retinopathy is graded by severity (Keith-Wagener-Barker classification), and acute severe hypertension produces characteristic microvascular changes — NOT retinal detachment. ### Features Present in Hypertensive Retinopathy | Feature | Pathophysiology | Location | |---------|-----------------|----------| | Flame-shaped hemorrhages | Rupture of precapillary arterioles | Nerve fiber layer (superficial) | | Cotton-wool spots | Nerve fiber layer ischemia/infarction | Around optic disc and macula | | Hard exudates (macular star) | Lipid leakage from damaged capillaries | Macula, arranged radially | | Microaneurysms | Weakening of capillary walls | Deep retinal layers | | Optic disc swelling | Axoplasmic stasis from arteriolar compression | Optic nerve head | **High-Yield:** The macular star pattern (lipid exudates radiating from the fovea) is a hallmark of acute hypertensive retinopathy and indicates severe disease requiring urgent BP control. ### Why Retinal Detachment Is NOT a Feature **Clinical Pearl:** Retinal detachment is NOT a primary manifestation of hypertensive retinopathy. It may occur secondarily in: - Proliferative diabetic retinopathy (tractional detachment) - High myopia or trauma - Retinopathy of prematurity - Advanced age-related macular degeneration Hypertensive retinopathy causes microvascular changes and hemorrhages but does NOT mechanically detach the retina. The pathophysiology is vasculitis and endothelial damage, not vitreous traction or retinal breaks. **Warning:** Do not confuse hypertensive retinopathy with diabetic retinopathy or other causes of retinal detachment. The question tests whether you recognize that retinal detachment is NOT part of the hypertensive retinopathy spectrum. ### Keith-Wagener-Barker Grading 1. **Grade 1:** Arteriolar narrowing only 2. **Grade 2:** Grade 1 + arteriovenous nicking 3. **Grade 3:** Grade 2 + flame hemorrhages, cotton-wool spots, hard exudates 4. **Grade 4:** Grade 3 + optic disc swelling (malignant hypertension) **Mnemonic:** **CHEMO** for acute hypertensive retinopathy findings: - **C**otton-wool spots - **H**emorrhages (flame-shaped) - **E**xudates (hard, macular star) - **M**icroaneurysms - **O**ptic disc edema
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