Retinal hemorrhages indicate 
Stage 3 hypertensive retinopathy

ICD-10 Diagnosis Codes:

H35.031–Hypertensive retinopathy, right eye
H35.032–Hypertensive retinopathy, left eye
H35.033–Hypertensive retinopathy, bilateral


Hypertensive Retinopathy


Other Retinal Disorders


Hypertensive retinopathy is damage to the retina from high blood pressure.

Hypertension produces many ophthalmic manifestations.  Because of the structural differences between the retina, the choroid, and the optic nerve, the vascular response to systemic hypertension varies according to the anatomic region. 

Retinal response
to chronic hypertension:

  • Arteriolosclerosis (generalized narrowing of the retinal blood vessels)
  • Copper wiring and silver wiring of retinal arterioles secondary to arteriosclerosis
  • Arteriovenous nicking secondary to arteriosclerosis
  • Retinal hemorrhages
  • Nerve fiber layer fallout
  • Increased tortuosity of retinal blood vessels
  • Remodeling of blood vessels due to capillary nonperfusion

Choroidal response
to chronic hypertension:

  • Areas of the retinal pigment epithelium (RPE) atrophy and form focal white lesions
  • Choroidal ischemia
  • Serous retinal detachment secondary to retinal pigment epithelial necrosis

Hypertensive retinopathy is a risk factor for systemic morbidity and mortality.  The Atherosclerosis Risk in Communities (ARIC) study demonstrated that hypertensive retinopathy is strongly associated with elevated blood pressure, but variable in its association with elevated cholesterol and other risk factors for atherosclerosis.

Mild hypertensive retinopathy (focal arteriolar narrowing and arteriovenous nicking) are weakly associated with systemic vascular disease.  More severe presentations (microaneurysms, hemorrhages and cotton-wool spots) have astrong association with subclinical cerebrovascular disease, stroke, congestive heart failure and cardiovascular mortality.

Structural Damage to the Eye

  • Retinal hemorrhages
  • Optic neuropathies
  • Cranial neuropathies
  • Subconjunctival hemorrhages
  • Arteriovenous nicking
  • Cotton-wool spots
  • Retinal and macular edema
  • Lipid deposits
  • Macular star

Functional Damage to the Eye and Visual System

  • No visual, physical or ocular symptoms
  • Headaches
  • Blurred vision

The main goal of the diagnostic evaluation in a patient with hypertensive retinopathy is to accomplish the following:

  • Determine the presence or absence of hypertensive retinopathy
  • Classify the hypertensive retinopathy
  • Identify and exclude differential diagnosis
  • Determine if the retinopathy is clinically significant and/or vision threatening
  • Prescribe a treatment program

Patient History

The severity of the symptoms or signs is varied and depends on severity of the retinal/choroidal changes.  Patients can present with the following abnormal symptoms:

  • Blurred vision (sudden or gradual)
  • Distorted vision (sudden or gradual)
  • Difficulty driving at night
  • Floaters or dark spots in their field of view

Clinical Appearance of the Retina

The retinal changes associated with hypertensive retinopathy include the following:

  • Hemorrhages
  • Microaneurysms
  • Cotton-wool spots
  • Edema
  • Ischemia
  • Venous beading
  • Intraretinal microvascular abnormalities
  • Retinal thickening
  • Increased retinal vessel tortuosity
DG36211Pic03a Grade 3 Hypertensive Retinopathy

  • Cotton-wool spots are fluffy white lesions found in the retinal nerve fiber layer
  • Lesions occur secondary to ischemia 
  • Most commonly found at the posterior pole
  • Usually lasts approximately 3-6 weeks before fading away
  • Fluorescein angiography reveals hypofluorescence secondary to vascular nonperfusion and capillary dropout


Fundus Photography

  • To document the progress or lack of progress of hypertensive retinopathy
  • To document the delivery of medical treatment
  • To document the response to treatment
  • To help plan a treatment program
  • Fundus autofluorescence imaging can be used to detect structural abnormalities and predict functional deficits
201a Retinal Hemorrhage Secondary to Hypertensive Retinopathy — Initial Visit

  • 67-year-old black female with hypertension
  • Optic disc hemorrhage discovered on routine ophthalmoscopy
  • Hemorrhage appears as a flame-shaped or splinter-like lesion at the superior border of the optic disc

Optic Disc Hemorrhage May Be Associated With The Following:

  • Hypertension
  • Diabetes
  • Normal-tension glaucoma
  • Aspirin use
101a Same Patient As Above — 8 Days Later

  • Retinal hemorrhage is absorbed within 8 days
  • No permanent structural damage to the optic nerve or retina
  • No functional loss of vision

Optic Disc Hemorrhage — Pathophysiology

  • Vasculopathy associated with systemic hypertension and diabetes can cause microinfarctions and ischemic changes in optic disc vessels, making these vessels vulnerable to mechanical rupture

Retinal Scanning Laser

  • To measure the microscopic anatomy of the retina and vitreoretinal interface
  • To measure the effectiveness of therapy
  • To help in determining the need for ongoing therapy
  • To determine the safety of cessation of therapy

Visual Field Examination

  • Used to assess visual function and determine the size of any associated visual field defects
  • Visual field may be affected depending on the size and location of retinal hemorrhaging the extent of the visual field defect depends on size of macular edema

B-Scan Ophthalmic Ultrasound

  • A two-dimensional ultrasonic scanning procedure used to produce cross-sectional images of the eye and orbit
  • B-scan ophthalmic ultrasound can be used to assess internal structures of the eye when a vitreous hemorrhage prevents proper visualization and examination of the retina
  • The test results are used to determine whether the retina is attached or detached

In 1953, Scheie developed a staging system for hypertensive retinopathy ranging from normal to the most severe retinal changes.

HTN1ab Grade 0 Hypertensive Retinopathy

  • Patient diagnosed with hypertension
  • No visible retinal vascular abnormalities
DG36211Pic01a Grade 1 Hypertensive Retinopathy

  • Diffuse retinal arteriolar narrowing
  • Blood vessel caliber is uniform, with no focal constriction
DG36211Pic100 Grade 2 Hypertensive Retinopathy

  • Narrowing of the retinal arterioles
  • Blood vessel caliber is not uniform (arteriovenous nicking)
DG36211Pic03ab Grade 3 Hypertensive Retinopathy

  • Focal and diffuse arteriolar narrowing
  • Retinal hemorrhages may be present
  • Cotton-wool spots may be present
HTN4a Grade 4 Hypertensive Retinopathy

All of the previously listed retinal abnormalities may be present in addition to the following:

  • Retinal and macular edema
  • Hard exudates
  • Optic disc edema



CT_ICD9_362-05_041809a Diabetic Retinopathy

  • The abnormal clinical findings are very similar to moderate hypertensive retinopathy (e.g., microaneurysms, hemorrahges and cotton-wool spots)
  • Hard exudates are usually not found in hypertensive retinopathy but are common in diabetic retinopathy
1a (2) Optic Disc Hemorrhage Secondary to Vitreopapillary Detachment

  •  Hemorrhage is actually of the optic disc surface
  • Bleeding is from mechanical trauma as opposed to a vascular problems
DG36201Pic41a Retinal Venous Obstruction

  • Central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO) can produce retinal hemorrhages similar in appearance, however the onset of CRVO and BRVO are sudden versus hypertensive retinopathy’s clinical signs which usually develop over time
  • Decreased visual acuity is a common finding in vein occlusions but not hypertensive retnopathy
DG3201Pic35a Retinal Telangectasia

  • Pathologically dilated blood vessels leak fluid into the retinal tissue
  • Exudative formation secondary to fluid retention is similar in appearance to the exudates found in diabetic retinopathy, but not hypertensive retinopathy
  • Exudate formation is seen in severe, long-standing cases and there would be other clinical signs of hypertensive retinopathy in addition to the presence of the exudates
DG36201Pic38a Leukemia

Ocular manifestations of leukemia can produce the following retinal vessel changes

  • microaneurysms
  • blood vessel dilation
  • neovacularization
  • cotton wool spots
exudative lesion Ocular Manifestations of HIV

  • Acute retinal necrosis as seen in an HIV-positive patient
  • Similar to hypertensive retinopathy cotton-wool spots

Treatment for hypertensive retinopathy involves evaluation of secondary causes and appropriate medical co-management with the patient’s primary care doctor.  Lowering blood pressure would be the primary course of action in reducing the risk of further retinal changes.

Several studies report that hypertensive retinopathy may regress over a 6-12 month period with control of elevated blood pressure. 

  • Patients with mild clinical signs can usually be managed with with routine care and the target blood pressure range should be based on established guidelines
  • Patients with moderate clinical signs may benefit from additional assessment of vascular risk (e.g., measurement of cholesterol levels) and appropriate risk reduction therapy
  • Patients with severe clinical signs need urgent anti-hypertensive treatment (e.g., intravenous medication)

The following systemic medications can be used to lower blood pressure:

  • Calcium channel blockers
  • Diuretics
  • Angiotensin receptor blockers
  • Angiotensin converting enzyme (ACE) inhibitors
  • Anti-andrenergics
  • Vasoconstrictors
  • Renin inhibitors

And, of course, exercise and proper diet have long been a means of improving cardiovascular health. 

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