# Hypertensive (arteriosclerotic) retinopathy - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Hypertensive Retinopathy - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK525980/ · Egyptian National Drug Formulary - Cardiovascular Chapter 2024 (amlodipine monograph, Hypertension, chronic) · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class FD67.00 - condition scope only, no dose - Verified date: 2026-09 ## Verified against - Egyptian National Drug Formulary - Cardiovascular Chapter 2024 (amlodipine monograph, Hypertension, chronic) - Hypertensive Retinopathy - StatPearls - NCBI Bookshelf (NBK525980) - https://www.ncbi.nlm.nih.gov/books/NBK525980/, Treatment / Management ## Treatment metadata - Amlodipine — 5 mg — oral.solid - Grading, eye referral and the systemic work-up (Referral & Advice) ## Complete treatment card ```text HYPERTENSIVE (ARTERIOSCLEROTIC) RETINOPATHY Sources: Hypertensive Retinopathy - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK525980/ · Egyptian National Drug Formulary - Cardiovascular Chapter 2024 (amlodipine monograph, Hypertension, chronic) · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class FD67.00 - condition scope only, no dose Review status: REVIEWED against 2 sources listed above (2026-09) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (2) - Malignant hypertension can present with headaches or a decline in vision in both eyes [hypertension] - The retinal finding is more often picked up incidentally on a routine eye exam than through symptoms SIGNS - what you find (11) - The Salus sign is a vein deflecting where it crosses an arteriole, giving a vertical hump or an S-shaped bend - The Gunn sign is tapering of the vein on either side of an AV crossing from arterial compression - The Bonnet sign is banking or widening of the vein just past the crossing point, which can precede a branch vein occlusion - The artery-to-vein width ratio can narrow from the normal 2:3 down to as low as 1:3 - Early arteriolar sclerosis widens and brightens the vessel's central light reflex, giving a burnished copper appearance (copper wiring) - In advanced sclerosis, the vessel wall becomes so opaque the artery looks like a white cord despite blood still flowing through it (silver wiring) - Bleeding in the deep retina shows as dot-blot hemorrhages, while bleeding in the superficial nerve fiber layer shows as flame-shaped hemorrhages [bleeding] - Cotton wool spots are soft exudates from nerve fiber ischemia, distinct from hard exudates, which are lipid deposits [ischaemia] - A macular star from hard exudate deposits becomes more visible once the surrounding fluid resolves [rash] - Papilledema with blurred disc margins and radial flame hemorrhages around the disc defines the malignant form - AV nicking can be a clue to long-standing hypertension even when the current blood pressure reading is normal [hypertension] TESTS (7) - The diagnosis is made by direct visualization of the retina during a dilated fundus exam - The Keith-Wagener-Barker system's group 4 adds papilledema on top of the group 3 hemorrhage and exudate findings - The Scheie system grades acute retinopathy changes and chronic arteriolosclerosis on two separate scales - OCT can show subretinal fluid at the fovea, usually continuous with swelling around the optic disc, in the malignant form - Fluorescein angiography can show microaneurysms, capillary dropout, leaky vessels, and sometimes new vessel growth - Because of the risk of kidney involvement, a nephrology referral is considered essential - Repeated blood pressure measurement, and in younger patients a work-up for a secondary cause such as kidney disease, are part of the systemic evaluation IF NOT THIS - what else fits (4) - Idiopathic intracranial hypertension, anterior ischemic optic neuropathy, and optic neuritis can also cause disc swelling and enter the differential - Central retinal vein occlusion, diabetic papillopathy, neuroretinitis, radiation papillopathy, and a retrobulbar tumor are other causes of disc swelling to rule out - Diabetic retinopathy and retinal vein obstruction can mimic the chronic form of this condition - Hyperviscosity syndrome, ocular ischemic syndrome, radiation retinopathy, and anemia or other blood disorders can also mimic the chronic changes Source StatPearls "Hypertensive Retinopathy" - disease-level clinical article Status traced to the source above Rx: Blood pressure - the treatment for the retinopathy | Referral and the eye BLOOD PRESSURE - THE TREATMENT FOR THE RETINOPATHY 1. AMLODIPINE [1st line] Adult 2.5 to 5 mg once daily initially; evaluate the response after 2 to 4 weeks and titrate as needed to a maximum of 10 mg once daily. If more control is needed, consider combination therapy - long-term Peds Age restriction: minimum 72 months (The formulary licenses amlodipine for hypertension in children of 6 years and over, and gives a set amount rather than a weight-based one: "Children >=6 years and Adolescents: Oral: Initial: 2.5 mg once daily; titrate based on clinical response; maximum dose: 10 mg/day." Hypertensive retinopathy in a child is unusual and points to a secondary cause, so the reason for the hypertension is the thing to chase.) Choice Alternatives, all four named by the article as primary classes for long-term control: angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, thiazide diuretics and calcium-channel blockers, with beta-blockers, alpha-blockers and vasodilators as further options. The article does not rank them. Choose as you would for hypertension itself - the hypertension card carries that comparison. Source Egyptian National Drug Formulary - Cardiovascular Chapter 2024 (amlodipine monograph, Hypertension, chronic). That blood pressure control is the treatment for this condition, and the classes used for it, come from Hypertensive Retinopathy - StatPearls - NCBI Bookshelf (NBK525980) - https://www.ncbi.nlm.nih.gov/books/NBK525980/, Treatment / Management Why The retinopathy is the eye's record of the blood pressure, so the treatment is the blood pressure. The article: "Hypertensive retinopathy, including papilledema and macular subfoveal fluid, often improves with adequate systemic control, particularly blood pressure regulation and management of renal dysfunction" and "Primary drug classes for long-term blood pressure control include angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, thiazide diuretics, and calcium channel blockers." A calcium-channel blocker is one of those four and needs no electrolyte monitoring, which suits a first prescription; the fuller comparison of antihypertensives is on the hypertension card. Caution RED FLAG - Untreated malignant hypertensive retinopathy is lethal, not just a threat to sight. The article: "In untreated malignant cases, mortality reaches up to 50% within 2 months and nearly 90% within 1 year of diagnosis." Retinal findings of this severity are a reason for urgent referral and urgent treatment, not a routine follow-up. RED FLAG - In a hypertensive crisis the pressure is lowered in a controlled way, not abruptly. The article: "Most guidelines recommend reducing the mean arterial pressure (MAP) by 10% to 15% in the first hour and no more than 25% of baseline within the first 24 hours during a hypertensive crisis", because a faster drop causes ischaemic injury to the optic nerve, kidneys and brain. Management there begins with intravenous drugs in hospital - the article names labetalol, nicardipine, clevidipine, fenoldopam, esmolol and sodium nitroprusside - and transitions gradually to oral agents. That is a hospital job, and no intravenous dose is printed here. Ankle oedema is dose-related and common with amlodipine. Avoid in severe aortic stenosis, and use the lower starting dose in severe hepatic impairment. No dose change is needed for any degree of kidney impairment. Look for what else is damaging the same vessels. The article says moderate cases warrant referral to a physician to evaluate coexisting diabetes mellitus and cardiovascular abnormalities, and that assessment of target-organ damage in the kidneys, cardiovascular system and brain is critical. Some retinal change does not reverse. "Retinal changes can stabilize with effective treatment of hypertension, although arteriolar narrowing and vessel crossing changes often remain" - so a persistent finding on a later fundoscopy is not proof the treatment failed. Egypt CORONAVINE 5 MG 10 TAB. PHAROPHARMA 6.00 EGP (0.60/unit) WINDIPINE 5 MG 30 TAB. SANOFI 21.00 EGP (0.70/unit) VASOPINE 5 MG 30 TABS. ARAB DRUG COM... 24.00 EGP (0.80/unit) AMILO 5 MG 30 TAB. ALFACURE PHAR... 54.00 EGP (1.80/unit) AMLODIPINE 5 MG 30 TAB. AMRIYA 60.00 EGP (2.00/unit) MYODURA 5 MG 30 TAB. GLOBAL NAPI P... 69.00 EGP (2.30/unit) NORVASC 5MG 10 TAB. PFIZER > VIAT... 54.00 EGP (5.40/unit) NORVASC 5MG 30 TAB. PFIZER > VIAT... 162.00 EGP (5.40/unit) REFERRAL AND THE EYE 2. GRADING, EYE REFERRAL AND THE SYSTEMIC WORK-UP (REFERRAL & ADVICE)[2nd line] Adult Retinal changes from long-standing or poorly controlled hypertension; hypertension is extremely common in Egyptian primary care. The GP's actionable step is tightening blood pressure control with the drug above, and referring to ophthalmology for grading and monitoring. The article sets the referral threshold by severity: mild cases are managed with blood pressure control and regular monitoring; moderate cases warrant referral to a physician to look for coexisting diabetes and cardiovascular disease; severe cases demand urgent intervention and referral. - Refer, with advice Peds The pathway is the same in a child, and the amlodipine row above carries the paediatric dose from 6 years. Hypertension severe enough to mark the retina in a child needs its cause found. Source No dose - grading and referral pathway, from Hypertensive Retinopathy - StatPearls - NCBI Bookshelf (NBK525980) - https://www.ncbi.nlm.nih.gov/books/NBK525980/, Treatment / Management Why Retinal changes from long-standing or poorly controlled hypertension; hypertension is extremely common in Egyptian primary care. The GP's actionable step is tightening blood pressure control with the drug above, and referring to ophthalmology for grading and monitoring. The article sets the referral threshold by severity: mild cases are managed with blood pressure control and regular monitoring; moderate cases warrant referral to a physician to look for coexisting diabetes and cardiovascular disease; severe cases demand urgent intervention and referral. Caution Systemic control comes first, before any eye injection. The article reports intravitreal bevacizumab improving macular oedema in a small case series where subfoveal fluid persisted despite adequate systemic treatment, but states that "Systemic control should always be prioritized before considering intravitreal therapy, given the associated risks, including endophthalmitis and potential blood pressure dysregulation", and that the role of anti-VEGF agents requires further investigation. This is an ophthalmologist's decision, not a primary-care one. The fundus is not proof of the cause. Optic disc swelling also occurs in idiopathic intracranial hypertension, anterior ischaemic optic neuropathy, optic neuritis, central retinal vein occlusion, diabetic papillopathy, neuroretinitis, radiation papillopathy and a retrobulbar tumour; and chronic hypertensive change is mimicked by diabetic retinopathy, retinal venous obstruction, hyperviscosity syndrome, ocular ischaemic syndrome, radiation retinopathy and anaemia. Chronic hypertensive retinopathy rarely causes significant visual loss - which is worth saying to a frightened patient - but the same article gives the malignant form a mortality of up to 50% at 2 months untreated. The grading is what separates those two conversations. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)