bmj.com Rapid Responses for van den Born et al., 331 (7508) 73

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PAPERS:
Bert-Jan H van den Born, Caroline A A Hulsman, Joost B L Hoekstra, Reinier O Schlingemann, and Gert A van Montfrans
Value of routine funduscopy in patients with hypertension: systematic review
BMJ 2005; 331: 73 [Abstract] [Full text]

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Rapid Responses published:

Value of routine funduscopy: Zvonko Rumboldt (8 July 2005)

Nothing Changes At All: Erlon O A Silva (8 July 2005)

Fundoscopy of patients suspected of having hypertension should not be discouraged: Petros Aristodemou (9 July 2005)

Re: Value of routine funduscopy: Bert-Jan H van den Born, Gert A van Montfrans (12 July 2005)

Re: Fundoscopy of patients suspected of having hypertension should not be discouraged: Bert-Jan H van den Born, Gert A. van Montfrans (12 July 2005)

Value of clinic BP measurement in patients with hypertension: Iddo Z. Ben-Dov (16 July 2005)

Hypertensive retinopathy signs are independent predictors of cardiovascular diseases: Tien Y Wong, Paul Mitchell, Professor, University of Sydney (24 July 2005)

Limited role for retinal fundoscopy in routine hypertension management: Simon B Dimmitt (27 July 2005)

Re: Hypertensive retinopathy signs are independent predictors of cardiovascular diseases: Bert-Jan H van den Born (9 August 2005)

Re: Limited role for retinal fundoscopy in routine hypertension management: Bert-Jan H. van den Born (9 August 2005)

Value of routine funduscopy 8 July 2005

Zvonko Rumboldt,
professor of medicine
Split University School of Medicine, �oltanska 2, 21000 Split, Croatia
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Re: Value of routine funduscopy

Sir, Although fundoscopy is less useful in the assessment of hypertensive patients than stated in most textbooks, I disagree with the conclusion of the van den Born & al. paper "Value of routine funduscopy in patients with hypertension: systematic review" (downloaded from bmj.com on July 8, 2005) that "funduscopy is of limited additional value in hypertensive patients..." for the following reasons:
1. Although the Keith, Wagener, and Barker classification grades I and II are not very informative, often mixed with atherosclerotic changes (we actually prefer modified classifications, omitting for instance the a- v nicking phenomena) and prone to subjectivity, funduscopy is still one of the most rewarding office examinations. We have recently shown on 440 consecutive hypertensives seen in our Outpatient clinic a good correlation between funduscopic changes and blood pressure level (e.g. 44.1% of 68 patients with diastolic blood pressure below 110 mm Hg were classified as grade 0, and 41.2% had grade I changes; among 322 patients with diastolic pressure between 111 and 130 mm Hg, 50.7% had grade II changes, 1.2% had grade III, and none grade IV; among 50 persons with DBP>130 mm Hg there were 22.0% with grade IV, and 18.0% with grade III changes)*.
2. Funduscopy is absolutely indicated in more severe forms of hypertension and in hypertensive emergencies/urgencies, where the presence/absence of retinal edema, haemorrhages or exudates rapidly discriminates a medical emergency from acute anxiety and other, non life- threatening conditions.
3. In addition to hypertensive alterations funduscopy may quickly disclose concomitant relevant pathology, e.g. advanced diabetic retinopathy.
4. In expert hands it takes just one minute or even less; a dark room and/or midryasis are seldom necessary, its cost is negligible, and the device's pocket size is suitable for busy practice.
*Rumboldt Z, Naranca M, Bagatin J, Pivac N. What did the last 10,000 patients teach us? Postered at Community Control of Hypertension with Special Emphasis on Central and Eastern Europe. WHL Conference, Prague, April 24, 2004.
Professor Zvonko Rumboldt, Past president, Croatian Society of Hypertension
Competing interests: None declared

Nothing Changes At All 8 July 2005

Erlon O A Silva,
Medstudent
Porto Alegre (Brazil) 90510-002
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Re: Nothing Changes At All

In the last JNC (1) and European Society of Hypertension Guidelines (2), although questioned, examination of the optic fundi is still recommended as part of the evaluation and follow-up of hypertensive subjects.
Last year, the Journal published The Beaver Dam Eye Study, by Wong et al (3), with specific data about the relationship between funduscopic abnormalities and the inicidence of hypertension. Other arms of this study entered in the analyses done by van der Born et al in this systematic review (4).
The authors outline the large interobserver variability of the retinal findings, and the low positive (47-72%) and negative (32-67%) predicitive values for the association between hypertensive retinopathy and blood pressure as limitations for its routine use. Moreover, the ophtalmological evaluation used in some of this studies cannot be implemented out of the experimental setting, at least for now, because of its cost.
Similar results were obtained in a cross-sectional survey, by Fuchs et al (5), demonstrating that optic fundi examination in a clinical setting does not give an accurate assessment of the severity of hypertension (positive and negative predicitive values 59% and 60%, respectively) and that the Keith-Wagener classification of retinopathy has limited applicability.
All this rational adds embasement to the concept of blood pressure levels themselves as the more confident markers for the incidence and progression of hypertension and its associated high cardiovascualr risk.
So, in the clinical scenario, nothing changes at all. The control of risk factors for the development of hypertension continues to be the rule and the accurate blood pressure measurement, the guideline (6).
References:
1- The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure � The JNC 7 Report. JAMA 2003; 289:2560-72
2- 2003 European Society of Hypertension � European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension 2003; 21:1011-53
3- Wong TY, Shankar A, Klein R, et al. Prospective cohort study of retinal vessel diameter and risk of hypertension. BMJ 2004;329;79- doi:10.1136/bmj.38124.682523.55
4- van den Born B-J, Hulsman CAA, Hoekstra JBL, et al. Value of routine funduscopy in patients with hypertension: systematic review. BMJ 2005;331;73- doi:10.1136/bmj.331.7508.73
5- Fuchs FD, Maestri MK, Bredemeier M, et al. Study of the usefulness of optic fundi examination of patients with hypertension with hypertension in a clinical setting. J Hum Hypertens 1995; 9: 547�551.
6- Silva EOA. Nothing Changes (eletronic letter). BMJ 2004; http://bmj.bmjjournals.com/cgi/eletters/329/7457/79
Competing interests: None declared

Fundoscopy of patients suspected of having hypertension should not be discouraged 9 July 2005

Petros Aristodemou,
Senior House Officer in Ophthalmology
Queen Mary's Hospital, Frognal Avenue, Sidcup, Kent, DA14 6LT
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Re: Fundoscopy of patients suspected of having hypertension should not be discouraged

EDITOR- Van der Bron et al have concluded that routine fundoscopy is of limited additional value in the routine management of patients with hypertension, except in emergency cases1. On the other hand, the authors have recognized that the presence of retinal signs of systemic hypertension is highly specific1,2,3. Therefore, one should not overlook the diagnostic value of hypertensive retinopathy.
White coat hypertension is common and it can pose diagnostic challenges4. The presence of retinal signs of systemic hypertension in such cases can confirm the diagnosis and reduce the need for blood pressure monitoring devices, which may not be available when resources are limited.
Petros Aristodemou Senior House Office in Ophthalmology Queen Mary's Hospital, Frognal Avenue, Sidcup, Kent, DA14 6LT
References:
1. Van den Born BJH, Hulsman CAA, Hoekstra JBL, Schlingemann RO, van Montfrans GA. Value of routine fundoscopy in patients with hypertension: systematic review. BMJ 2005; 331 73-76
2. Wang JJ, Mitchell P, Leung H, Rochtchina E, Wong TY, Klein R. Hypertensive retinal vessel wall signs in a general older population: the Blue Mountains Eye Study. Hypertension. 2003 Oct;42(4):534-41.
3. Klein R, Sharrett AR, Klein BE, Chambless LE, Cooper LS, Hubbard LD, Evans G. Are retinal arteriolar abnormalities related to atherosclerosis?: The Atherosclerosis Risk in Communities Study. Arterioscler Thromb Vasc Biol. 2000 Jun;20(6):1644-50.
4. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, Sever PS, Thom S McG. BRITISH HYPERTENSION SOCIETY GUIDELINES: Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004�BHS IV. Journal of Human Hypertension (2004) 18, 139�185
Competing interests: None declared

Re: Value of routine funduscopy 12 July 2005

Bert-Jan H van den Born,
research fellow
Academic Medical Centre, 1100 DD, Amsterdam, the Netherlands,
Gert A van Montfrans
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Re: Re: Value of routine funduscopy

Editor- The data provided by Rumboldt on the prevalence of hypertensive retinopathy in 440 consecutive patients visiting the outpatients clinic are interesting and in line with the conclusion of our systematic review. In the study by Rumboldt more than half of patients with hypertension did not have any signs of hypertensive retinopathy. Only in persons with severe hypertension (diastolic blood pressure > 130 mmHg) retinopathy consistent with grade III and IV of the Keith Wagener and Barker classification was a frequent finding. Because of their extremely elevated blood pressure a hypertensive emergency (i.e. malignant hypertension) should be suspected in these patients prior to funduscopy. The presence of these retinal findings mandates immediate treatment to lower blood pressure to safe (but not necessary normal) levels because cerebral autoregulation in these patients is disturbed. 1 2 As we have stated in our review the value of funduscopy in this particular group is not under dispute. Finally, we believe that the limited effort and opportunity to find concomitant retinal pathology is no reason to perform a diagnostic test with limited value.
References:
1. Vaughan CJ,.Delanty N. Hypertensive emergencies. Lancet 2000;356:411-7.
2. Immink RV, van den Born BJ, van Montfrans GA, Koopmans RP, Karemaker JM, van Lieshout JJ. Impaired cerebral autoregulation in patients with malignant hypertension. Circulation 2004;110:2241-5.
Competing interests: None declared

Re: Fundoscopy of patients suspected of having hypertension should not be discouraged 12 July 2005

Bert-Jan H van den Born,
research fellow
Academic Medical Centre, 1100 DD, Amsterdam, the Netherlands,
Gert A. van Montfrans
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Re: Re: Fundoscopy of patients suspected of having hypertension should not be discouraged

Editor � Aristodemou argues that because of the high specificity funduscopy may limit the need for (home) blood pressure monitoring in patients with white coat hypertension. Studies have shown that persons with white coat hypertension are at increased risk for sustained hypertension and have an elevated left ventricular mass.1 2 Therefore home blood pressure measurements would be an ideal method to establish the transition from white coat to sustained hypertension in these patients and may also be cost-effective in terms of doctors visit. Two small series have shown that the prevalence of hypertensive retinopathy in patients with white coat hypertension is higher than in normotensive persons.3 4 So, the presence (or absence) of hypertensive retinopathy cannot discriminate between white coat hypertension or sustained hypertension.
References:
1. Bidlingmeyer I, Burnier M, Bidlingmeyer M, Waeber B, Brunner HR. Isolated office hypertension: a prehypertensive state? J Hypertens 1996;14:327-32.
2. Muscholl MW, Hense HW, Brockel U, Doring A, Riegger GA, Schunkert H. Changes in left ventricular structure and function in patients with white coat hypertension: cross sectional survey. BMJ 1998;317:565-70.
3. Cerasola G, Cottone S, Nardi E, D'Ignoto G, Volpe V, Mule G, et al. White-coat hypertension and cardiovascular risk. J Cardiovasc Risk 1995;2:545-9.
4. Pose-Reino A, Gonzalez-Juanatey JR, Pastor C, Mendez I, Estevez JC, Alvarez D, et al. Clinical implications of white coat hypertension. Blood Press 1996;5:264-73.
Competing interests: None declared

Value of clinic BP measurement in patients with hypertension 16 July 2005

Iddo Z. Ben-Dov,
MD, MSc
Internal Medicine, Hadassah University Hospital, Mt-Scopus Campus, POB 24035, Jersalem, Israel 91240
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Re: Value of clinic BP measurement in patients with hypertension

Editor - In their systematic review of the clinical value of hypertensive retinopathy, van den Born and colleages acknowledge that photographic signs of hypertensive retinopathy can be found in subjects without history of hypertension (1,2). Furtheremore, signs of mild hypertensive retinopathy were found to predict hypertension in normotensive subjects (3). These findings suggest that arteriolar narrowing contributes to the pathogenesis of hypertension. Alternativley, they may indicate that the method used to diagnose hypertension, namely clinic blood pressure, was not sufficiently sensitive. Just as direct ophtalmoscopic examination is less sensitive and reproducible than retinal photography, the measurement of blood pressure in the clinic may erroneosly dismiss a hypertensive subject as being normotensive. These �masked� hypertensive subjects can be identified by an elevated blood pressure on ambulatory monitoring, which has been shown to have superior diagnostic and prognostic capabilities in comparrison to ordinary clinic blood pressure measurements (4). The prevalence of masked hypertension among reffered subjects was recently found to be 10-20% (5,6). Thus, it is propose that the finding of hypertensive-type retinal changes in a normotensive subject should suggest evaluation for masked hypertension.
Iddo Z. Ben-Dov, vp02292@netvision.net.il
1. van den Born BJ, Hulsman CA, Hoekstra JB, Schlingemann RO, van Montfrans GA. Value of routine funduscopy in patients with hypertension: systematic review. BMJ 2005;331(7508):73.
2. Wong TY, Mitchell P. Current concepts: Hypertensive retinopathy. N Engl J Med 2004;351:2310-7.
3. Wong TY, Klein R, Sharrett AR et al. Retinal arteriolar diameters and risk for hypertension. Ann Intern Med 2004;140:248-55.
4. Imai Y, Ohkubo T, Sakuma M, Tsuji I, Satoh H, Nagai K et al. Predictive power of screening blood pressure, ambulatory blood pressure and blood pressure measured at home for overall and cardiovascular mortality: a prospective observation in a cohort from Ohasama, Northern Japan. Blood Press Monit 1996;1:251-4.
5. Sega R, Trocino G, Lanzarotti A, Carugo S, Cesana G, Schiavina R, Valagussa F, Bombelli M, Giannattasio C, Zanchetti A, Mancia G: Alterations of cardiac structure in patients with isolated office, ambulatory, or home hypertension: Data from the general population (Pressione Arteriose Monitorate E Loro Associazioni [PAMELA] Study). Circulation 2001;104:1385-92.
6. Ben-Dov IZ, Ben-Arie L, Mekler J, Bursztyn M. In clinical practice, masked hypertension is as common as isolated clinic hypertension: predominance of younger men. Am J Hypertens 2005;18(5 Pt 1):589-93.
Competing interests: None declared

Hypertensive retinopathy signs are independent predictors of cardiovascular diseases 24 July 2005

Tien Y Wong,
Associate Professor
Centre for Eye Research Australia, University of Melbourne, Victoria 3002, Australia,
Paul Mitchell, Professor, University of Sydney
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Re: Hypertensive retinopathy signs are independent predictors of cardiovascular diseases

Editor-We read with interest the article by van den Born and colleagues on the value of routine fundoscopy in patients with hypertension (1). We agree that retinopathy signs are not specific for hypertension, but in patients with hypertension, these signs are strong predictors of systemic risk.
Their review suggests that the associations between hypertensive retinopathy and cardiovascular risk were inconsistent, except for retinopathy and stroke, and that there have been no data to show that the association of retinopathy and stroke are independent of other indicators of hypertensive organ damage (e.g., left ventricular hypertrophy, microalbuminuria and carotid intima-media thickness). In the Atherosclerosis Risk In Communities (ARIC) Study, we have recently reported that hypertensive retinopathy signs were associated with risk of congestive heart failure, independent of standard risk factors (2). We have now conducted further analysis on the association between hypertensive retinopathy and the 10-year risk of stroke and coronary heart disease in the same cohort. In models that adjusted for age, gender, race, hypertension status, diabetes status, mean arterial blood pressure, serum glucose, total cholesterol, cigarette smoking, left ventricular hypertrophy (as defined from ECG) and common carotid artery intima-media thickness (as defined from ultrasound), retinopathy signs (retinal hemorrhages, cotton wool spots and microaneurysms) were independently predictive of both incident stroke (relative risk [RR] 2.18, 95% confidence intervals [CI], 1.56, 3.05) and incident coronary heart disease (RR 1.39, 95% CI, 1.05, 1.82). In participants with hypertension only, associations were largely similar (RR 2.36, 95% CI, 1.64, 3.41 for stroke, and RR 1.42, 95% CI, 1.03, 1.97 for coronary heart disease).
Furthermore, a major part of the review was focused on the poor sensitivity and predictive value of retinopathy signs in detecting hypertension. The review suggests that �fundoscopy cannot reliably determine whether a patient is normotensive or hypertensive�. This is counter-intuitive. It does not make sense to examine the retina of a patient to diagnose hypertension; measuring the blood pressure is clearly more efficient. What is important is the potential for end-organ damage in a patient with hypertension, and fundoscopy (i.e., the presence of retinopathy) offers insights into this.
Finally, we would like to re-emphasize that the traditional classification system of hypertensive retinopathy by Keith, Wagner and Barker, although widely used, has well recognized limitations. We have proposed a somewhat simpler classification of hypertensive retinopathy signs into mild, moderate and malignant grades (3). We believe this may facilitate clinical description and usage between physicians and ophthalmologists. Recent data provide compelling evidence that hypertensive retinopathy signs reflect not only concurrent blood pressure levels, but may be markers of chronic blood pressure damage, as well as future hypertension risk (4,5). Thus, we believe that a retinal examination in patients with hypertension, particularly those with �white coat hypertension�, or those with borderline hypertension without other target organ damage, may provide additional clinical information to guide management and treatment. Until there is further evidence to prove otherwise, fundoscopy should remain an integral part of the clinical assessment of patients with hypertension.
References
1. van den Born BJ, Hulsman CA, Hoekstra JB, Schlingemann RO, van Montfrans GA. Value of routine funduscopy in patients with hypertension: systematic review. BMJ 2005;331:73.
2. Wong TY, Rosamond W, Chang PP, Couper DJ, Sharrett AR, Hubbard LD, Folsom AR, Klein R. Retinopathy and risk of congestive heart failure. JAMA 2005;293:63-9
3. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004;351:2310-7
4. Smith W, Wang JJ, Wong TY, Rochtchina E, Klein R, Leeder SR, Mitchell P. Retinal arteriolar narrowing is associated with 5-year incident severe hypertension. The Blue Mountains Eye Study. Hypertension 2004;44:442-7
5. Wong TY, Shankar A, Klein R, Klein BE, Hubbard LD. Prospective cohort study of retinal vessel diameters and risk of hypertension. BMJ 2004;329:79-82
Competing interests: None declared

Limited role for retinal fundoscopy in routine hypertension management 27 July 2005

Simon B Dimmitt,
Associate Professor
Royal Perth Hospital Kirkman House 10 Murray St Perth 6000 Western Australia
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Re: Limited role for retinal fundoscopy in routine hypertension management

Value of routine fundoscopy in patients with hypertension: systematic review
Limited role for retinal fundoscopy in routine hypertension management
EDITOR- We read with interest van den Born�s1 conclusion that routine fundoscopy is of limited value in the clinical evaluation of hypertensive patients. Unfortunately, in only reviewing the medical literature since 1990, the similar findings in our 1989 detailed study of 25 patients were overlooked.2 Our study failed to disclose any significant correlation between arteriovenous changes on retinal photographs and blood pressure, measured by clinic or ambulatory sphygmomanometry, probably principally because similar arteriovenous crossing changes are driven by smoking, diabetes and age, which considerably dilute and confound any relationship with blood pressure. We also found very poor inter-observer agreement, as in other studies.
Interestingly, quantitative albuminuria correlated best with blood pressure in our study. However, many factors can affect and confound quantitative albuminuria,3 reducing its clinical usefulness. The most useful diagnostic tool with which to corroborate a diagnosis of hypertension would appear to be ambulatory blood pressure, which is now very widely available. Clinicians have also come to increasingly accept some role for home blood pressure measurement, which helps distinguish �white-coat� hypertension and facilitates achieving targets.
Obviously, clinicians should nevertheless always think to refer their hypertensive patients for formal ophthalmological review in the event of any visual symptoms.
Simon Dimmitt Associate Professor
sdimmitt@bigpond.com
School of Medicine & Pharmacology, University of Western Australia, Royal Perth Hospital, Kirkman House, 10 Murray St, Perth 6000, Western Australia
Competing interests: None declared.
1 van den Born B-J, Hulsman CAA, Hoskstra JBL, Schingemann RO, van Montfrans GA. Value of routine fundoscopy in patients with hypertension: systematic review. Br Med J 2005 331:73
2 Dimmitt SB, West JNW, Eames SM, Gibson JM, Gosling P, Littler WA. Usefulness of ophthalmoscopy in mild to moderate hypertension. Lancet 1989 i:1103-1106.
3 Dimmitt SB, Lindquist TL, Mamotte CDS, Burke V, Beilin LJ. Urine albumin excretion in healthy subjects. Journal of Human Hypertension 1993 7:239-243.
Competing interests: None declared

Re: Hypertensive retinopathy signs are independent predictors of cardiovascular diseases 9 August 2005

Bert-Jan H van den Born,
research fellow
Dep. Internal Medecine, University of Amsterdam, 1100 DD, Amsterdam, the Netherlands
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Re: Re: Hypertensive retinopathy signs are independent predictors of cardiovascular diseases

Editor- We read with interest the comments and data provided by Wong et al. The authors suggest that it makes no sense to evaluate the diagnostic accuracy of funduscopy in persons with and without hypertension as hypertensive retinopathy is a sign of hypertensive organ damage rather than a sign of hypertension. We cannot but agree that the best method to establish hypertension is measurement of blood pressure. However, to evaluate the usefulness of funduscopy in hypertensive patients studying the association between hypertension and retinal signs is essential. Considering hypertensive retinopathy as a diagnostic test for hypertension (i.e. calculating diagnostic accuracy) helps in unraveling this association. The low sensitivity as reported in our review indicates that retinal signs are uncommon in hypertensive patients and that the number needed to screen, defined as the number of persons needed to find one with evidence of hypertensive organ damage, is high. The low positive predictive value demonstrates that almost half of the persons with retinal signs attributed to hypertension have normal blood pressure and that, apparently, other factors are important in the development of these retinal signs. In these cases retinopathy cannot be considered a sign of hypertensive organ damage.
We agree with the authors that the most important issue remains whether the presence of hypertensive retinopathy is an independent predictor of cardiovascular disease. In that sense the new data the authors provide on the association between hypertensive retinopathy and the 10-year risk of stroke and coronary heart disease are interesting, especially because they also account for other indicators of hypertensive organ damage. Awaiting the publication of this paper we cannot but speculate on the meaning of these results. The authors refer to a paper they have recently published which demonstrated that hypertensive retinopathy was associated with an increased risk of congestive heart failure (CHF), independent of standard risk factors. 1 In this population based follow-up study diabetic patients in particular had an elevated risk of CHF when retinopathy was present. However in persons with hypertension but without diabetes, the risk of CHF was not increased when retinopathy was present after correction for standard risk factors. There was no association between retinal microvascular signs and incident CHF after multivariate adjustment. So, the lack of association between retinal signs and CHF seems in support of the conclusion of our review. Two papers referred to by the authors examined the association between retinal microvascular changes and future hypertension risk. 2 3 The large intergrader variation in establishing these retinal microvascular signs, however, limits their value for clinical practice.
In conclusion, we believe that the risk of future hypertension can be best assessed by measuring blood pressure at home (in the case of white coat hypertension) or at the office and should not be influenced by the presence or absence of retinopathy. As stated in our review we think the additional value of funduscopy in the routine management of patients with hypertension still needs to be determined. New evidence, as suggested by the authors, may of course alter this conclusion.
References:
1. Wong TY, Rosamond W, Chang PP, Couper DJ, Sharrett AR, Hubbard LD, et al. Retinopathy and risk of congestive heart failure. JAMA 2005;293:63- 9.
2. Smith W, Wang JJ, Wong TY, Rochtchina E, Klein R, Leeder SR, et al. Retinal arteriolar narrowing is associated with 5-year incident severe hypertension: the Blue Mountains Eye Study. Hypertension 2004;44:442-7.
3. Wong TY, Shankar A, Klein R, Klein BE, Hubbard LD. Prospective cohort study of retinal vessel diameters and risk of hypertension. BMJ 2004;329:79.
Competing interests: None declared

Re: Limited role for retinal fundoscopy in routine hypertension management 9 August 2005

Bert-Jan H. van den Born,
research fellow
Dep. Internal Medecine, University of Amsterdam, 1100 DD, Amsterdam, the Netherlands
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Re: Re: Limited role for retinal fundoscopy in routine hypertension management

Editor- We thank Dimmitt for his comments. The elegant study performed by the author and colleagues which showed the lack of correlation between hypertensive retinopathy and blood pressure was, of course, not overlooked while preparing our review.1 We have limited our review to papers published since 1990 including all large population based studies which examined the associations between retinal signs, blood pressure and cardiovascular risk. Unfortunately, these artificial dividing lines leads to the exclusion of potentially interesting papers.
References:
1. Dimmitt SB, West JN, Eames SM, Gibson JM, Gosling P, Littler WA. Usefulness of ophthalmoscopy in mild to moderate hypertension. Lancet 1989;1:1103-6.
Competing interests: None declared