What is the recommended physical examination for patients with Hypertensive Emergency Retinopathy (HEVR)?

Physical Examination in Hypertensive Emergency Retinopathy

In patients with suspected hypertensive emergency retinopathy, fundoscopy is mandatory to detect retinal hemorrhages, microaneurysms, hard exudates, cotton wool spots, and papilledema, which indicate severe hypertensive retinopathy (grade III-IV) and carry high predictive value for mortality. 1

Essential Vital Sign Assessment

• Blood pressure measurement should be performed in both arms and at the lower limb to detect pressure differences that may indicate aortic dissection 1
• Repeated BP measurements over time are critical, as BP may fall considerably without antihypertensive medication in a significant proportion of patients 1
• Pupillary assessment for relative afferent pupillary defect (RAPD) is essential, as this corresponds to the level of retinal ischemia and predicts risk for neovascularization 1

Comprehensive Ophthalmologic Examination

Anterior Segment Evaluation

• Slit-lamp biomicroscopy must carefully examine for fine, abnormal new iris vessels, which indicate neovascularization 1
• Intraocular pressure (IOP) measurement is required 1, 2
• Gonioscopy prior to dilation is particularly important when iris neovascularization risk is high or IOP is elevated 1

Fundoscopic Examination Components

The fundoscopic examination should specifically identify:

• Grade III retinopathy findings: retinal hemorrhages, microaneurysms, hard exudates, and cotton wool spots 1
• Grade IV retinopathy findings: all grade III signs plus papilledema and/or macular edema, which indicate severe hypertensive retinopathy with high mortality risk 1
• Vitreous examination for hemorrhage, detachment, and pigmented cells 1
• Macular assessment for edema using both clinical examination and optical coherence tomography (OCT) 1
• Signs of ischemia: extensive hemorrhages, venous dilation and tortuosity, cotton wool spots 1
• Neovascularization of the disc (NVD) or elsewhere (NVE) 1
• Subretinal fluid, which occurs in 9-30% of hypertensive emergency cases and may cause distinctive visual field defects 3, 4

Peripheral Retinal Examination

• Dilated fundus examination using indirect ophthalmoscopy is recommended to ensure optimal view of the entire retina 1
• Scleral depression may be considered for thorough peripheral examination, though this is more relevant for other vitreoretinal pathology 1

Cardiovascular and Neurological Assessment

Physical examination must focus on detecting acute hypertension-mediated organ damage:

• Neurological examination for somnolence, lethargy, focal deficits, cortical blindness, or altered mental status that may indicate hypertensive encephalopathy 1
• Cardiac assessment including heart rate, presence of third or fourth heart sounds, murmurs, arrhythmias, and pulmonary rales 1
• Peripheral vascular examination for absent, reduced, or asymmetric pulses and cold extremities 1

Diagnostic Imaging

When fundoscopy reveals severe retinopathy or when media opacity precludes adequate examination:

• Optical coherence tomography (OCT) provides high-resolution imaging to detect macular edema, subretinal fluid, and vitreoretinal interface changes 1
• B-scan ultrasonography should be performed if media opacity or patient cooperation precludes adequate peripheral retina examination 1
• Fundus photography is useful for documenting severity of retinal findings and response to treatment 1

Critical Clinical Pitfalls

Common examination errors to avoid:

• Do not rely on absolute BP values alone to determine emergency status; the rate of BP increase and presence of organ damage are more important than the absolute value 1
• Focal neurological lesions are rare in hypertensive encephalopathy and should raise suspicion for intracranial hemorrhage or ischemic stroke rather than pure hypertensive retinopathy 1
• Fundoscopy should be performed by experienced examiners or using digital fundus cameras where available, as interobserver reproducibility is limited 1
• Vision complaints with elevated BP mandate fundus examination to distinguish hypertensive chorioretinopathy (more acute, increased morbidity) from isolated retinopathy 4

Laboratory and Ancillary Testing

Essential laboratory analysis includes:

• Hemoglobin, platelet count, creatinine, sodium, potassium, LDH, haptoglobin 1
• Quantitative urinalysis for protein and urine sediment examination 1
• 12-lead ECG for ischemia detection 1
• Troponin if cardiac involvement suspected 1