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Hypertensive retinopathy: comparing the


Keith-Wagener-Barker to a simplified
classification
ARTICLE in JOURNAL OF HYPERTENSION FEBRUARY 2013
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Original Article

Hypertensive retinopathy: comparing the Keith^


Wagener^Barker to a simplified classification
Laura E. Downie a, Lauren A.B. Hodgson b, Carly D0 Sylva b, Rachel L. McIntosh b, Sophie L. Rogers b,
Paul Connell c, and Tien Y. Wong b,d

Purpose: This study assessed the interobserver and


intraobserver grading reliability of the KeithWagener
Barker (KWB) system to the proposed MitchellWong
simplified three-grade classification for hypertensive
retinopathy.
Methods: Digital retinal images of normal and
hypertensive human fundii (n 50 per group) were
randomly graded by an optometrist and an
ophthalmologist using the two systems. Interobserver
agreement was compared to a gold standard research
grader. Intraobserver agreement was assessed through a
repeat grading after 6 months. Cohens kappa coefficients
were used to assess the degree of agreement.
Results: Both clinicians demonstrated a good level of
agreement with the KWB and simplified classification
compared with a gold standard grader; there was no
significant difference in the level of agreement for
either of the two classification methods for either observer.
The simplified classification was found to be equally as
efficacious as the KWB system with respect to
interobserver and intraobserver agreement for both
practitioners.
Conclusion: These findings indicate that the simplified
classification of hypertensive retinopathy is both reliable
and repeatable. The advantage of the simplified method
over the KWB system in correlating retinal microvascular
signs to incident cardiovascular risk supports its adoption
in clinical practice.
Keywords: arteriovenous nicking, cardiovascular disease,
cotton wool patch, hemorrhage, hypertension,
hypertensive retinopathy, KeithWagenerBarker,
microvasculature, retina

Pressure (JNC) and the European Society of Hypertension


and Cardiology, may be indicative of end-organ damage
[35].
Despite these recommendations, few physicians
routinely examine the retina for signs of hypertensive
retinopathy. There is currently no clear consensus regarding the classification of hypertensive retinopathy or
whether a retinal examination is useful to stratify risk [6].
Previous studies have often been limited by unreliable
techniques with poor interobserver and intraobserver
correlations [7,8]. Furthermore, few studies cite the link
between hypertensive retinopathy and incident cardiovascular signs, frequently only citing increased mortality
as the collapsible collective end-point [911].
The usefulness of the traditional classification scheme
[KeithWagenerBarker (KWB)] originally proposed by
Keith et al. [11] (and subsequently modified by Scheie
et al. [9]) on the basis of clinical descriptions by Marcus
Gunn [12] is questioned [1318]. There are two major
criticisms of these original and modified classifications,
which categorize the commonly observed hypertensive
retinal signs (i.e. generalized and focal arteriolar narrowing,
arteriovenous nicking, flame-shaped and blot-shaped
hemorrhages, cotton wool spots and optic disk swelling)
into four grades of increasing severity. First, it can be
difficult for the clinician to distinguish between low grades
of retinopathy (i.e. grade 1 vs. grade 2). Second, the
retinopathy grade cannot be easily correlated to the severity
of the hypertension [19,20].
We have previously proposed a simplified three-grade
classification scheme (simplified classification) based on
the strength of the reported associations between hypertensive retinopathy and cardiovascular risk [21]. We suggest
that this may be more useful than the KWB classification.

Abbreviation: KWB, KeithWagenerBarker classification


of hypertensive retinopathy
Journal of Hypertension 2013, 31:000000
a

Department of Optometry and Vision Sciences, University of Melbourne, Parkville,


Centre for Eye Research Australia (CERA), University of Melbourne, cVitreo-retinal
Unit, The Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia and
d
Singapore Eye Research Institute, National University of Singapore, Singapore
b

INTRODUCTION

irst described by Liebreich in 1859 [1], hypertensive retinopathy is a condition characterized by a


spectrum of retinal vascular signs in patients with
elevated systemic arterial blood pressure [2]. Routine ophthalmoscopic evaluation of the retina, as recommended and
supported by the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood
Journal of Hypertension

Correspondence to Dr Laura E. Downie, Lecturer and Clinical Leader - Cornea and


Contact Lenses, Department of Optometry and Vision Sciences, University of
Melbourne, Parkville, VIC 3010, Australia. Tel: +61 3 8344 7008; fax: +61 3 9035
9905; e-mail: ldownie@unimelb.edu.au
Received 18 November 2012 Revised 8 January 2013 Accepted 15 January 2013
J Hypertens 31:000000 2013 Wolters Kluwer Health | Lippincott Williams &
Wilkins.
DOI:10.1097/HJH.0b013e32835efea3

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Downie et al.
TABLE 1. KeithWagenerBarker and simplified classification systems for hypertensive retinopathy
KWB

Simplified classification

Grade

Features

Grade

Features

1
2

Mild generalized retinal arteriolar narrowing


Definite focal narrowing and arteriovenous nipping

None
Mild

Signs of grade 2 retinopathy plus retinal hemorrhages,


exudates and cotton wool spots

Moderate

Severe grade 3 retinopathy plus papilledema

Malignant

No detectable signs
Generalized arteriolar narrowing, focal arteriolar narrowing,
arteriovenous nicking, opacity (copper wiring) of arteriolar
wall or a combination of these signs
Retinal hemorrhages (blot-shaped, dot-shaped, or flame-shaped),
microaneurysm, cotton wool spot, hard exudate or a combination
of these signs
Signs of moderate retinopathy plus swelling of the optic disk

KWB, KeithWagenerBarker.

The aim of this study was to assess the interobserver and


intraobserver grading reliability between the simplified
classification system and KWB classification systems for
hypertensive retinopathy.

grading were 0.784 and 0.683 for the optometrist and retinal
specialist, respectively; the interobserver kappa between
the two clinicians was 0.660.

Intraobserver agreement

MATERIALS AND METHODS


Sets of digital retinal images (n 100, which comprised
of two 458 fields per set, one image centered on the optic
disk and one on the macula) of normal (n 50) and
hypertensive (n 50) human fundii were randomly graded
by two clinicians, an optometrist (L.E.D.) and an ophthalmologist (P.C., retinal specialist) using two hypertensive
grading systems: grade 1, KWB and grade 2, simplified
classification (Table 1). Images were assessed on FastStone
Image Viewer for Windows (version 4.0, 2009; FastStone
Soft).
The interobserver level of agreement for the clinical
observers was analyzed for grades 1 and 2. The interobserver agreement of both clinical observers was
also compared with a gold standard research grader
(L.A.B.H.), grading coordinator at the Centre for Eye
Research Australia (CERA). The intraobserver level of
agreement for both hypertensive grading systems was
determined through a second grading by the same observers,
using a randomly selected subgroup of 25 image sets
per grading system, performed 6 months after the original
grading. Cohens kappa coefficients were calculated to
assess the degree of agreement for both interobserver
and intraobserver correlations. The degree of agreement
is expressed in the form of kappa (standard error). Kappa is
interpreted qualitatively using the following criterion: poor
agreement, <0.20; fair agreement, 0.200.40; moderate
agreement, 0.400.60; good agreement, 0.600.80; very
good agreement, 0.801.00 [22].

RESULTS
Interobserver agreement
Statistical data summarizing the interobserver level of
agreement are provided in Table 2. For the KWB system,
the interobserver kappa values for grading when compared
with the gold standard grading were 0.724 and 0.661 for
the optometrist and retinal specialist, respectively; the
interobserver kappa between the two clinicians was
0.661. For the simplified system, the interobserver kappa
values for grading when compared with the gold standard
2

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Statistical data summarizing the intraobserver level of


agreement over time are provided in Table 3. For the
KWB system, the intraobserver kappa values were
0.770 and 0.702 for the optometrist and retinal specialist,
respectively. For the simplified system, the interobserver
kappa values were 0.879 and 0.671 for the optometrist and
retinal specialist, respectively.

DISCUSSION
This study has compared the interobserver and intraobserver level of agreement between an optometrist and
a retinal specialist, for categorizing degrees of hypertensive
retinopathy from digital retinal images, using the KWB
and the proposed simplified classification system. Both
clinicians demonstrated a good level of agreement with
the KWB and the simplified classification system compared
with a gold standard grader; there was no significant
difference in the level of agreement for either of the two
classification methods, for either observer. The degree of
interagreement between the two clinicians also did not
differ significantly for either hypertensive classification
system. Intraobserver agreement, as measured using a
repeat grading by each clinician at a time point 6 months
after the initial grading, revealed that both the optometrist
and retinal specialist demonstrated a good level of
classification agreement using the KWB system. For the
simplified classification system, intraobserver agreement
was rated as very good and good for the optometrist and
retinal specialist, respectively.
At present, there is no well established consensus regarding the optimal method of classification for hypertensive
TABLE 2. Interobserver agreement [kappa (standard error),
n 100 image sets] for KeithWagenerBarker and
the simplified hypertensive classification systems

Vs. gold standard


Optometrist
Retinal specialist
Optometrist vs. retinal specialist

KWB

Simplified

0.724 (0.06)
0.661 (0.06)
0.661 (0.06)

0.784 (0.07)
0.683 (0.07)
0.660 (0.07)

KWB, KeithWagenerBarker.

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Hypertensive retinopathy: a simplified classification


TABLE 3. Intra-observer agreement [kappa (standard error),
n 25 image sets] for KWB and the simplified
classification systems

Optometrist
Retinal specialist

KWB

Simplified

0.770 (0.12)
0.702 (0.12)

0.879 (0.14)
0.671 (0.14)

KWB, KeithWagenerBarker.

retinopathy in clinical practice. A search of the published


literature indicates that this is the first study to have
compared the clinical repeatability and reliability of the
KWB and simplified classification of hypertensive retinopathy. The study design enabled the comparison of two
representatives from professional populations that are likely
to commonly observe hypertensive retinopathy in practice,
namely practitioners in primary ocular care (optometrists)
and those undertaking tertiary ophthalmic care (retinal
specialists). Our findings indicate that the more recently
(a)

proposed simplified classification by Wong and Mitchell [21]


was comparable to the KWB system [11] with respect to both
interobserver and intraobserver agreement for both clinical
observers. These data confirm that both classification
systems can be easily performed by clinicians. Furthermore,
our findings predict that good agreement should exist
between assessments performed between different practitioners and by the same practitioner over time.
Given that both the KWB and simplified classification
systems demonstrate similar interobserver and intraobserver grading reliability, a decision with regard to the
clinical usefulness of each system requires consideration of
the how the assessment of retinal microvascular change
might be meaningfully correlated to the risk of cardiovascular pathology. Formulated over 70 years ago, the
KWB scale remains the most widely cited grading system
for hypertensive retinopathy; the system is referred to in
leading ophthalmology and cardiology textbooks [2326]
and is thus taught to medical students and residents during
their training. The KWB system has also been utilized for
(b)

AV nicking

Focal arteriolar
narrowing

Copper wiring

AV nicking

(c)

(d)
Retinal hemorrhage
Cotton wool patch
Retinal hemorrhages
Retinal hemorrhage

Retinal hemorrhage

Cotton wool patch

(e)

(f)
Cotton wool patch

Cotton wool patch


Retinal hemorrhage
Optic disc swelling
Optic disc swelling
Hard exudate

Retinal hemorrhage
Hard exudate

Retinal hemorrhage

FIGURE 1 Representative digital retinal fundus photographs of mild (a, b), moderate (c, d), and malignant (e, f) hypertensive retinopathy, as graded with the simplified
classification. (a) Mild hypertensive retinopathy is indicated by the presence of generalized arteriolar narrowing, arteriovenous nicking and opacification of the arteriolar
wall (copper wiring). (b) Mild hypertensive retinopathy with focal arteriolar narrowing. (c and d) Moderate hypertensive retinopathy with multiple retinal hemorrhages and
cotton wool patches. (e and f) Malignant hypertensive retinopathy with swelling of the optic disk, retinal hemorrhages, hard exudates, and cotton wool patches.

Journal of Hypertension

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Downie et al.
TABLE 4. Summary of the association between the simplified classification of hypertensive retinopathy and cardiovascular disease
outcomes
Grade

Retinal signs

Cardiovascular disease outcomea

None
Mild

No detectable signs
Generalized arteriolar narrowing, focal arteriolar narrowing,
arteriovenous nicking, opacity (copper wiring) of arteriolar
wall or a combination of these signs
Hemorrhage (blot-shaped, dot-shaped, or flame-shaped),
microaneurysm, cotton wool spot, hard exudate or a
combination of these signs

None
Modest association with risk of incident stroke [23],
subclinical stroke [41], renal dysfunction [27],
incident coronary heart disease [25,28], and death [43]
Strong association with risk of incident stroke [23,24],
cardiovascular mortality [29], cognitive decline [42],
transient ischemic attack, and acute ischemic stroke [30],
and stroke mortality [31]
Strong association with death [11]

Moderate

Malignant
a

Signs of moderate retinopathy plus swelling of the optic disk

Modest association is denoted by an odds ratio greater than 1 but less than 2. Strong association is denoted by an odds ratio greater than 2.

the classification of retinopathy in many recent clinical


studies on hypertension [2731].
However, an important limitation of the KWB classification is the lack of clinical usefulness in differentiating
grade 1 from grade 2 retinopathy. The Ibaraki Prefectural
Healthy study, involving 87 890 Japanese individuals,
identified mild hypertensive retinopathy (i.e. grade 1 or

2 on KWB) as a significant, independent risk factor for


cardiovascular mortality [27]. Other recent studies have also
demonstrated an association between mild hypertensive
retinopathy (i.e. grade 1 or 2 on KWB) and incident
cardiovascular outcomes and indicators of target organ
damage. Individual signs of mild hypertensive retinopathy such as focal arteriolar narrowing and arteriovenous

(a)
6.35

CWS
4.71

Microaneurysm

4.24

Blot hemorrhage
1.69

AV nicking

1.49

Generalized narrowing

1.16

Focal narrowing

0.74

No retinopathy
0

3-year cumulative incidence of stroke (%)

(b)
19.1

CWS

18.7

Hemorrhage

17.3

Microaneurysm
AV nicking

8.0

Generalized narrowing

8.1
7.2

Focal narrowing
4.8

No retinal signs
0.0

5.0

10.0

15.0

20.0

25.0

7-year cumulative incidence of heart failure (%)


FIGURE 2 (a) Graph showing the association between the severity of hypertensive retinal microvascular change and the 3-year cumulative risk of incident stroke
(data derived from Wong et al., 2001) [33]. (b) Graph showing the association between the severity of hypertensive retinal microvascular change and the 7-year cumulative
risk of congestive heart failure (data derived from Wong et al., 2005) [47]. AV nicking, arteriovenous nicking; CWS, cotton wool spots.

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Hypertensive retinopathy: a simplified classification

nicking are associated with subclinical stroke [32], incident


clinical stroke [33,34], stroke mortality [35], coronary artery
disease [36], left ventricular hypertrophy [37], and renal
dysfunction [38]. These findings add to the recent growing
body of evidence that even mild hypertensive retinopathy is
of prognostic significance for patients with hypertension.
However, in all these studies, there is no indication that risk
of cardiovascular disease and target organ damage differs
between grade 1 and 2 signs.
The simplified classification of hypertensive retinopathy
is based upon more recent evidence [39], arising from
studies that demonstrate that there are differences in
the risk of cardiovascular disease and target organ damage
between mild (grades 1 and 2 on KWB) and moderate
(grade 3 on KWB) retinopathy, and thus the rationale for a
single category of mild stage that combines KWB grades 1
and 2. The primary advantage of the simplified classification system over the KWB classification is that it allows
for the stratification of clinically observable retinal vascular
changes (see Fig. 1) to the risk of cardiovascular disease
(summarized in Table 4).
In this simplified classification, the features of mild
hypertensive retinopathy, which encompass retinal arteriolar signs only, have been demonstrated to be modestly
associated with the risk of coronary heart disease and
associated disorders [3336,38,40]. However, the presence
of moderate hypertensive retinopathy on the simplified
classification, including retinal hemorrhage, cotton wool
spots, and hard exudates, is not only indicative of more
substantial retinal microvascular disorder but also holds
a strong association with an increased risk of clinical
stroke, subclinical stroke, cognitive decline, and death from
cardiovascular causes [33,4145]. The association between
the heightened risk of an adverse cardiovascular outcome
and higher levels of hypertensive retinopathy is evident in
the risk stratification for both stroke and congestive heart
failure (Fig. 2). The simplified classification system therefore allows the clinician to utilize the eyes vascular status as
a hypertensive target organ for risk stratification.
Continued advancements in vascular imaging technologies are allowing the development of newer and more
specific approaches for assessing the retinal vasculature,
such as the quantitative measurement of retinal vascular
caliber changes and/or global geometric retinal vascular
patterning [46]. Although these techniques are highly
valuable in improving our understanding of retinal parameters to assess cardiovascular risk, the complexity and
cost of these more advanced analysis techniques currently
limits their application to the domain of clinical research;
thus, these techniques have not yet translated into mainstream practice. The simplified classification, based upon
recent data and correlated to the severity of systemic
vascular disease, is therefore more relevant to daily clinical
practice and for the optimal management of patients with
hypertension.
Although our observers consisted of only one representative from each profession, we would expect the
performance of these individuals to be typical of each
professional population. A follow-up study involving
an increased number of practitioners, with a larger sample
of digital retinal photographs for assessment, would be of
Journal of Hypertension

value to confirm this. These preliminary results suggest that


the simplified classification of hypertensive retinopathy is
a clinically relevant, reliable, and repeatable method
of assessing retinal microvascular pathology. Given the
advantage of this method being correlated to the severity
of systemic vascular disease, we propose the usefulness
of this methodology in clinical practice in grading
hypertensive retinopathy and correlating these changes
to incident cardiovascular risk.

ACKNOWLEDGEMENTS
Conflicts of interest
The authors do not have any potential conflicts of interest
relevant to this research. CERA receives operational
infrastructure support from the Government of Victoria.

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Reviewers Summary Evaluations


Reviewer 1
In their paper Downie et al. evaluated the inter- and intraobserver grading reliability of the three-grade classification
system as introduced by Wong and Mitchell in 2004 in
comparison to the traditional four-grade classification system of hypertensive retinopathy as introduced by Keith,
Wagener and Barker in 1939. The authors found that the
inter- and intra-observer reliabilities of the two classification
systems are comparable. This is of interest as the WongMitchell classification system is based on prognostic
significance of retinal findings on clinical cardiovascular
outcomes observed in more recent population based
studies. Clearly, current hypertensive patients receiving
cardioprotective treatment might differ from those hypertensive patients with uncontrolled blood pressure levels
that lived at the times of Keith, Wagener and Barker.

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Therefore, a classification system of hypertensive retinopathy based on more recent data and its reliability is of
interest. The study is straight forward. The statistical analyses
performed are sound. The manuscript is well written.

Reviewer 2
The authors propose a new classification of hypertensive
retinopathy that is in good agreement with the Keith,
Wagener and Barker classification. The KeithWegener
Barker grading system was widely applied in the last
decades for the stratification of risk in hypertensive
patients. However, several studies have proved a weak
clinical usefulness of this classification, due to poor reproducibility and poor association with other indices of target
organ damage. This limits extensive clinical application of
the examination of the fundus oculi. Newer approaches,
such as that proposed by the authors, could potentially give
us better information about retinal damage in hypertension.

Volume 31  Number 00  Month 2013

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