Snapshot A 58-year-old man is referred to his ophthalmologist for progressive visual loss. Medical history is remarkable for essential hypertension, which he has been nonadherent to antihypertensive medication, lisinopril. His systolic blood pressures have been in the 160s for the past 6 years. Slit-lamp examination is notable for arterial narrowing, arteriovenous nicking, and silver wiring. Introduction An ocular manifestation of hypertension Pathophysiology Hypertension damages the retinal vasculature acute increases in blood pressure causes reversible retinal blood vessel vasoconstriction chronic blood pressure leads to endothelial damage, leading to exudative vascular changes Epidemiology Incidence the most common ocular presentation of hypertension Risk factors hypertension high salt diet obesity tobacco use alcohol use family history Presentation Symptoms decreased visual acuity Physical exam acute hypertension flame-shaped hemorrhage cotton-wool spots represents foci of retinal ischemia yellow hard exudates optic disc edema chronic hypertension arterial narrowing arteriovenous nicking copper and silver wiring Differential Diabetic retinopathy differentiating factor poorly controlled diabetes DIAGNOSIS Clinical diagnosis Treatment Medical antihypertensive therapy indication first-line treatment Prognosis patients are at increased risk for retinal artery occlusion retinal vein occlusion retinal macroaneurysms