A 55-year-old hypertensive patient is found to have an arteriovenous (AV) nicking at the superior temporal arcade on routine fundoscopy. There are also flame-shaped haemorrhages and cotton wool spots near the disc, with disc oedema. This fundus picture is most consistent with which grade of hypertensive retinopathy using the modified Keith-Wagener-Barker (KWB) classification?

• A Grade I: mild arteriolar narrowing only
• B Grade II: AV nicking and moderate arteriolar narrowing without haemorrhages
• C Grade IV: all Grade III changes plus papilloedema (disc oedema) ✓
• D Grade III: flame haemorrhages, cotton wool spots, and hard exudates without papilloedema

Explanation

The Keith-Wagener-Barker classification grades hypertensive retinopathy from I to IV. Grade IV (malignant hypertension) includes all features of Grade III (haemorrhages, cotton wool spots/soft exudates, hard exudates) PLUS papilloedema (disc swelling/oedema) reflecting breakdown of autoregulation in the optic nerve head vasculature. Disc oedema in hypertensive retinopathy is a sign of malignant (accelerated) hypertension, a medical emergency requiring urgent but controlled blood pressure reduction. AV nicking alone without haemorrhages is Grade II.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.