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The vasculature in the retina can be viewed directly and non-invasively in vivo, offers a unique perspective of the human microvasculature, and therefore the ability to understand early changes, processes, pathways and consequences of hypertension. In the past 15 years, advances in high resolution digital retinal photography and automated or semi-automated computer image software have been applied to measure and quantify a variety of retinal microvascular parameter, including retinal arteriolar and venular caliber, tortuosity, branching patterns and fractal dimensions. Clinical and epidemiological studies show that hypertension is strongly associated with many of these retinal microvascular changes. Concurrently, these retinal parameters are associated with a range of systemic conditions, including subclinical target organ damage (e.g., silent cerebral infarctions, myocardial perfusion, vascular remodelling, left ventricular hypertrophy and microalbuminuria) as well as clinical outcomes (e.g., clinical stroke, myocardial infarction, congestive heart failure, chronic kidney disease, cardiovascular mortality). Furthermore, some of the retinal measures are seen in children at risk of hypertension (e.g., higher BMI or low birth weight) and normotensive patients before they subsequently develop hypertension, suggesting that retinal microvascular changes may reflect the vascular remodelling processes in early hypertension. There are increasing data from genome-wide association studies that indicate genetic influence on retinal vascular caliber, possibly providing new genetic markers of systemic vascular diseases. Retinal vascular imaging provides the opportunity to interrogate early, subclinical microcirculatory effects associated with elevated blood pressure, and thus new insights into the pathogenesis and vascular consequences of hypertension.

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