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Retinopathy: Diabetic & Hypertensive — Key Differences (MRCP Part 1)

TL;DR:

MRCP Part 1 commonly tests your ability to distinguish diabetic retinopathy from hypertensive retinopathy using fundoscopy patterns and clinical context. Diabetic retinopathy reflects chronic microvascular damage from hyperglycaemia, while hypertensive retinopathy reflects arteriolar injury from raised blood pressure. Recognising hallmark signs (microaneurysms vs AV nicking), severity markers, and exam traps reliably converts this topic into marks.


Why this matters for MRCP Part 1

Retinopathy sits at the intersection of endocrinology, cardiovascular medicine, and neurology. MRCP Part 1 questions frequently present fundoscopy findings without naming the diagnosis, requiring pattern recognition rather than recall. Candidates who can rapidly separate capillary disease (diabetes) from arteriolar disease (hypertension) perform consistently well in SBA and image-based items.

For syllabus context, see the official MRCP Part 1 overview:https://www.mrcpuk.org/mrcpuk-examinations/part-1


What this article covers

  • Core pathological differences

  • Fundoscopy features most commonly tested

  • Exam-relevant grading systems

  • One short MCQ with explanation

  • Five common examiner traps

  • A practical revision checklist


Core differences at a glance (high-yield table)

Feature

Diabetic Retinopathy

Hypertensive Retinopathy

Primary pathology

Chronic hyperglycaemia → capillary damage

Raised BP → arteriolar vasoconstriction/sclerosis

Vessels involved

Capillaries

Arterioles

Earliest sign

Microaneurysms

Generalised arteriolar narrowing

Haemorrhages

Dot/blot

Flame-shaped

Hard exudates

Common

Uncommon

Cotton-wool spots

Seen in advanced disease

Seen in moderate–severe disease

AV nicking

Absent

Characteristic

Papilloedema

Late, severe disease

Malignant hypertension

Diabetic retinopathy — exam essentials

Diabetic retinopathy results from loss of pericytes, basement membrane thickening, and capillary leakage, leading to retinal ischaemia and neovascularisation.


Subtypes tested in MRCP Part 1

  1. Background (non-proliferative)

    • Microaneurysms (earliest sign)

    • Dot-blot haemorrhages

    • Hard exudates

  2. Pre-proliferative

    • Cotton-wool spots

    • Venous beading

    • Intraretinal microvascular abnormalities (IRMAs)

  3. Proliferative

    • Neovascularisation

    • Vitreous haemorrhage

    • Tractional retinal detachment

Key exam points

  • Microaneurysms are pathognomonic for diabetic retinopathy.

  • Maculopathy can occur at any stage and is a common exam trap.

  • Tight glycaemic and blood pressure control slows progression (management context).

Authoritative guidance:

Hypertensive retinopathy — exam essentials

Hypertensive retinopathy reflects arteriolar vasospasm and sclerosis from sustained or acute blood pressure elevation.

Keith–Wagener–Barker classification (exam-relevant)

  1. Grade I: Mild generalised arteriolar narrowing

  2. Grade II: AV nicking; copper wiring

  3. Grade III: Flame haemorrhages, cotton-wool spots, exudates

  4. Grade IV: Papilloedema (malignant hypertension)

Key exam points

  • AV nicking is not a feature of diabetic retinopathy.

  • Papilloedema implies end-organ damage and malignant hypertension.

  • In younger patients, consider secondary causes of hypertension.

Clinical background reference:https://www.bmj.com/content/344/bmj.e1812


Medical student revising fundoscopy and retinopathy patterns for MRCP Part 1 exam

How MRCP Part 1 typically tests this topic

Expect:

  • Fundoscopy images with minimal history

  • “Most likely diagnosis” or “most likely association” questions

  • Links to systemic disease (e.g. malignant hypertension → papilloedema)

Targeted practice improves speed and accuracy. Use a mixed ophthalmology block in a high-quality MRCP question bank, for example:https://www.passmedicine.com/mrcp/


Mini-case (MCQ style)

A 60-year-old man with a 12-year history of type 2 diabetes attends routine review. Fundoscopy shows microaneurysms, dot-blot haemorrhages, and hard exudates. There is no AV nicking. What is the most likely diagnosis?

A. Hypertensive retinopathyB. Proliferative diabetic retinopathyC. Background diabetic retinopathyD. Central retinal vein occlusionE. Age-related macular degeneration

Correct answer: C — Background diabetic retinopathy

Explanation: Microaneurysms and hard exudates are classic for background diabetic retinopathy. Proliferative disease requires neovascularisation, which is not described. AV nicking would suggest hypertensive retinopathy.


Common pitfalls (exam favourites)

  • Assuming cotton-wool spots are specific to diabetes

  • Missing AV nicking in hypertensive retinopathy images

  • Thinking papilloedema occurs commonly in diabetes

  • Forgetting that maculopathy can occur without proliferative disease

  • Overcalling proliferative diabetic retinopathy without neovascularisation


Practical study-tip checklist

  • Decide first: capillary disease or arteriolar disease?

  • Learn one defining sign for each condition (microaneurysm vs AV nicking).

  • Pair fundoscopy findings with systemic clues (diabetes duration, BP history).

  • Practise image-based questions under time pressure.

  • Revise only exam-relevant grading systems.


FAQs

How do you differentiate diabetic and hypertensive retinopathy in MRCP Part 1?

Look for microaneurysms and hard exudates in diabetic retinopathy versus arteriolar narrowing and AV nicking in hypertensive retinopathy.

Are cotton-wool spots specific to diabetic retinopathy?

No. Cotton-wool spots reflect retinal ischaemia and are seen in both diabetic and hypertensive retinopathy.

Which finding suggests malignant hypertension?

Papilloedema, often with haemorrhages and exudates, indicates malignant hypertension.

Can diabetic maculopathy occur without proliferative disease?

Yes. Maculopathy can occur at any stage of diabetic retinopathy.


Ready to start?

For exam-focused ophthalmology revision, combine this guide with targeted MCQs in the Crack Medicine Qbank and timed practice using full MRCP mock tests.


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