Keeping an Eye on Hypertension Risk in the Ophthalmology Clinic

More than half of adults with diabetes had unrecognized or inadequately controlled hypertension detected during ophthalmology care, a prospective case series showed.

Among 172 patients, 91 had stage 2 hypertension and 18 met criteria for hypertensive crisis, as defined by clinical guidelines. The vast majority of the cohort had a prior diagnosis of hypertension, and 91% of those were receiving treatment for the condition. About 80% of the patients with diagnosed hypertension considered their blood pressure (BP) control good or excellent. Ultimately, 60% of the patients were advised to contact their primary care clinicians, and 12% required expedited follow-up.

The findings suggest that opportunistic blood pressure screening in ophthalmology clinics is feasible and may identify patients with actionable cardiovascular risk, reported Michael Cusick, MD, MHSA, of the University of Virginia School of Medicine in Charlottesville, and colleagues in JAMA Ophthalmology.

“The marked discordance between patients’ perception of adequate BP control and objectively measured values underscores the potential need for systematic BP assessment at ophthalmology visits,” the authors concluded. “Although the study’s single-site design, limited sample size, and referral-based clinic population preclude definitive conclusions about absolute prevalence across all practice settings, the consistency of these findings with prior studies in diverse ophthalmic populations strengthens the evidence base for incorporating BP measurement into retina clinic workflows.”

In an accompanying commentary, Rishi P. Singh, MD, of Mass Eye and Ear and Harvard Medical School in Boston, noted that the findings are “sobering” and challenge the clinical paradigm of ophthalmology clinics as “downstream recipients of systemic disease rather than active participants in broader chronic disease surveillance.”

“These findings reinforce an increasingly important reality in retina practice: Retinal disease often reflects broader systemic vascular instability,” he wrote. “The retina, with its uniquely visible microvasculature, provides a biologic window into endothelial dysfunction, microvascular injury, and chronic hemodynamic stress.”

For patients with diabetes, uncontrolled hypertension may hasten progression toward proliferative retinopathy, established across multiple lines of evidence, he added. However, the overarching message of the study should not be oversimplified, as the goal is not “indiscriminate intensification of blood pressure treatment from the ophthalmology clinic.”

“Rather, the practical opportunity identified by [the study authors] is more focused: routine ophthalmic encounters may reveal uncontrolled or unrecognized systemic vascular risk that warrants confirmation, communication, and coordinated medical follow-up,” Rishi noted.

“Importantly, this article should not be interpreted as advocating that ophthalmologists become hypertension specialists,” he continued. “Rather, it supports a more integrated care model in which ophthalmology participates in the identification and referral of patients at elevated systemic risk.”

In patients with diabetes, elevated blood pressure plays a central role in the onset and progression of retinopathy and vision-threatening complications, the authors noted in their introduction. Several studies have confirmed the association between hypertension and diabetic retinopathy across diverse populations. Good BP control has been shown to reduce the risk of microvascular and macrovascular complications.

Ophthalmology clinics offer a unique opportunity to screen and monitor hypertension, especially in patients with vascular comorbidities, such as diabetes, the authors continued. In the current case series, the investigators evaluated the prevalence of elevated or uncontrolled BP in diabetic patients receiving ophthalmology care.

The study involved consecutive adults with diabetes (type 1 or type 2) seen from July to August 2024 at a single academic retina clinic. All study participants had in-clinic BP measurement and completed a structured survey that covered hypertension history, monitoring, perceived control, and knowledge. Additional data were collected from electronic medical records.

The primary outcome was the prevalence of elevated BP and hypertension stage as defined by 2017 American College of Cardiology/American Heart Association criteria. Data analysis included 172 patients who had a mean age of 66.6 and a slight majority of men (51.2%).

Only 8.1% of patients had normal blood pressure. A majority (52.9%) had stage 2 hypertension (≥140 mm Hg systolic or ≥90 mm Hg diastolic), and 10.5% were in hypertensive crisis (>180 mm Hg systolic or >120 mm Hg diastolic). The data showed that 83.7% of patients had a prior hypertension diagnosis. Among 28 patients without a hypertension diagnosis, 24 had above-normal BP, including 10 with stage 2 hypertension and three in hypertensive crisis.

Of the 144 patients with a history of hypertension, 91% were receiving antihypertensive therapy, and 69.4% said they believed they had good or excellent BP control. However, 79.9% had stage 1 or greater hypertension.

The findings are particularly noteworthy in that they came from a study population that was “meaningfully engaged in medical care,” the authors pointed out. “These findings are clinically salient given the well-established pathophysiologic vulnerability of the retinal vasculature.”

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