Fundoscopy in a 50-year-old hypertensive man reveals scattered flame-shaped hemorrhages and multiple cotton-wool spots in both fundi. The optic discs are sharp with no swelling. Using the Keith-Wagener-Barker classification, what grade of hypertensive retinopathy is present?

• A Grade I
• B Grade II
• C Grade IV
• D Grade III ✓

Explanation

Keith-Wagener grading runs from grade I with generalized arteriolar narrowing, through grade II with AV nicking, to grade III with hemorrhages and cotton-wool spots, and grade IV adds papilledema. Hemorrhages and exudates without disc edema therefore define grade III. The absence of papilledema excludes grade IV, which is the single discriminating finding between the top two grades and corresponds to malignant hypertension. Grades I and II show vascular changes only, without retinal lesions.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.