A 58-year-old man admitted with accelerated hypertension has fundus examination showing flame-shaped hemorrhages, cotton wool spots, and bilateral optic disc edema. According to the Keith-Wagener-Barker classification, what grade of hypertensive retinopathy does this represent?

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

Explanation

Keith-Wagener-Barker grade IV is defined by the presence of optic disc edema superimposed on the changes of grades I to III (generalized and focal arteriolar narrowing, AV nipping, hemorrhages and cotton wool spots). Grade III includes hemorrhages and exudates but the disc is normal. Disc swelling in a hypertensive patient automatically places the patient in grade IV and indicates malignant hypertension requiring urgent blood pressure control.

Reference: Kanski's Clinical Ophthalmology, 9th ed.

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