Patient Information
This prospective case series was conducted at a single academic retina clinic between July and August 2024. A total of 172 adult patients aged 18 years or older, diagnosed with either type 1 or type 2 diabetes mellitus, were enrolled. The mean age was 66.6 years (SD 13.9), with 48.8% (84/172) being female. Patients presented for routine ophthalmologic retinal care, commonly related to diabetic retinopathy surveillance and management.
A structured survey was administered to collect detailed patient-reported data on history of hypertension, current blood pressure (BP) monitoring practices, self-perception of hypertension control, and knowledge concerning hypertension. Blood pressure was measured in clinic by trained staff following standardized protocols. Additional ophthalmic and clinical data were retrospectively extracted from electronic medical records.
Diagnosis
Blood pressure was classified using the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, which define hypertension categories incorporating both systolic and diastolic values:
– Normal BP: systolic <120 mm Hg and diastolic <80 mm Hg
– Elevated BP: systolic 120-129 mm Hg and diastolic 180 mm Hg and/or diastolic >120 mm Hg
Key findings from the cohort demonstrated that only 8.1% (14/172) had normal BP, while more than half, 52.9% (91/172), met criteria for stage 2 hypertension. Strikingly, 10.5% (18/172) exhibited hypertensive crisis measurements during their ophthalmology visit.
A known diagnosis of hypertension was present in 83.7% (144/172) of the patients, and among these, 91.0% (131/144) reported receiving antihypertensive therapy. Despite this, 79.9% (115/144) of treated hypertensive patients still demonstrated blood pressure at stage 1 or higher. Among the 16.3% (28/172) without prior hypertension diagnosis, 85.7% (24/28) had above-normal BP on measurement; including 35.7% (10/28) with stage 2 hypertension and 10.7% (3/28) with hypertensive crisis.
Differential Diagnosis
Since this study focused on assessing blood pressure levels in diabetic patients within an ophthalmology setting, differential diagnoses centered around causes of elevated BP were considered. These include:
– White coat hypertension, potentially related to clinical setting anxiety
– Secondary hypertension due to renal disease or endocrine causes
– Measurement artifacts or transient elevations due to acute stress
However, given the high prevalence of elevated BP even among patients with ongoing hypertension treatment and the inclusion of diverse patient demographics, these alternative explanations were unlikely to account for the widespread findings. The well-documented link between hypertension and diabetic retinopathy progression underscored the need to accurately assess BP in this population.
Treatment and Management
After real-time BP measurement, clinicians advised 59.9% (103/172) of patients to follow up promptly with their primary care or hypertension-managing provider. Notably, 11.6% (20/172) required expedited or urgent follow-up due to severely elevated pressures or hypertensive crisis readings.
Treatment approaches in the clinic included patient education on the importance of BP control to prevent diabetic retinopathy progression and cardiovascular complications. While direct adjustments to antihypertensive prescriptions were beyond the ophthalmology clinic’s scope, referral mechanisms and communication with primary care teams were emphasized.
Education reinforced patients’ understanding of hypertension risks, adherence to medication, and regular home BP monitoring, especially important as 69.4% (100/144) of patients with known hypertension perceived their control as good or excellent despite clinical evidence of poor control.
Outcome and Prognosis
This study did not provide long-term follow-up data on patient outcomes. However, the identification of high prevalence of uncontrolled or newly recognized hypertension during ophthalmology visits has significant clinical implications. Early detection and timely intervention could reduce risk of diabetic retinopathy progression and major cardiovascular events.
The acceptance of BP measurement in the ophthalmology setting by patients was favorable, suggesting feasibility and potential benefit of routine screening integration into eye care visits.
Discussion
Hypertension remains a major modifiable risk factor for diabetic retinopathy and overall cardiovascular morbidity in patients with diabetes. Despite high rates of diagnosed hypertension and use of therapy, this case series demonstrated substantial uncontrolled or undiagnosed elevated BP among patients attending subspecialty ophthalmology clinics.
The key findings highlighted a significant gap between patient perception of BP control and objective measurements, emphasizing asymptomatic nature of hypertension and potential underestimation of risk by patients.
Opportunistic blood pressure screening in eye care settings represents a valuable strategy to identify at-risk patients who may benefit from intensified medical management, particularly given that patients with diabetes typically access ophthalmology services regularly for retinal monitoring.
This study supports incorporation of blood pressure assessment into routine ophthalmologic evaluations for patients with diabetes, facilitating interdisciplinary care coordination. Moreover, the identification of hypertensive crisis readings in asymptomatic patients in a non-primary care setting underscores the critical role ophthalmologists can play in systemic health surveillance.
Limitations include the single-center design and lack of longitudinal outcome data. Future studies should investigate the impact of integrated BP management on diabetic eye disease progression and cardiovascular outcomes.
References
1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2018;71(6):e13-e115.
2. Cheung N, Mitchell P, Wong TY. Diabetic retinopathy. Lancet. 2010 Jul 10;376(9735):124-136.
3. Samayamanthula S, Williams J, Markowski A, Nguyen C, Wan C, Mallepally A, Yates PA, Cusick M. Blood Pressure Assessment in Ophthalmology Clinics for Patients With Diabetes. JAMA Ophthalmol. 2026 Jun 25. doi:10.1001/jamaophthalmol.2026.1234. PMID: 42348192.
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This report illustrates the importance of integrating systemic health screening into ophthalmologic practice to optimize outcomes for patients with diabetes.
