Fundus Examination in Pulmonary Edema and Hypertension
Neither pulmonary edema nor pulmonary hypertension are contraindications for fundus examination; in fact, fundoscopy is specifically recommended when blood pressure exceeds 180/110 mmHg to evaluate for hypertensive emergency and malignant hypertension. 1
When Fundoscopy is Indicated
The 2024 ESC Guidelines explicitly recommend fundoscopy in two specific clinical scenarios:
- Severe hypertension (BP >180/110 mmHg) during the work-up of hypertensive emergency and malignant hypertension 1
- Hypertensive patients with diabetes mellitus 1
These recommendations prioritize identifying end-organ damage that directly impacts mortality and morbidity, particularly detecting hypertensive retinopathy, papilledema, or retinal hemorrhages that indicate malignant hypertension requiring urgent intervention.
Clinical Context and Safety
Fundus examination is a non-invasive procedure that involves direct visualization of the retina using an ophthalmoscope. There are no physiological mechanisms by which this examination would worsen pulmonary edema or pulmonary hypertension, as it does not involve:
- Hemodynamic stress or changes in blood pressure 1
- Alterations in fluid status 2
- Respiratory compromise 3
- Cardiac workload increase 4
Important Clinical Pearls
The presence of pulmonary edema in a hypertensive patient actually strengthens the indication for fundoscopy because it suggests possible hypertensive emergency with multi-organ involvement. 1 The combination of severe hypertension (≥180/110 mmHg) and pulmonary edema warrants immediate evaluation for:
- Hypertensive retinopathy (grades III-IV) indicating malignant hypertension 1
- Papilledema suggesting elevated intracranial pressure 1
- Retinal hemorrhages or exudates indicating acute vascular damage 1
In patients with pulmonary hypertension, fundoscopy may reveal unexpected findings such as serous retinal detachment, though this is rare and typically associated with severe idiopathic pulmonary arterial hypertension. 5
Common Pitfall to Avoid
Do not confuse pulmonary hypertension with systemic hypertension. While fundoscopy is recommended for severe systemic hypertension (BP >180/110 mmHg), pulmonary hypertension itself does not require routine fundoscopy unless the patient also has severe systemic hypertension or diabetes. 1 However, pulmonary hypertension is not a contraindication if fundoscopy is otherwise indicated.
The only true contraindication to fundoscopy would be patient inability to cooperate or acute globe injury—neither pulmonary edema nor pulmonary hypertension fall into this category. 1