Scheie Classification (Hypertensive Fundus): Grades Guide

Scheie classification grades hypertensive and arteriolosclerotic fundus changes on two separate scales.

Harold Scheie published the system in 1953, after Keith, Wagener and Barker described their combined groups.

Therefore, a complete report carries two grades, for example H2 S1.

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Why the Scheie Classification Uses Two Scales

Blood pressure can injure retinal arterioles quickly, while sclerosis develops over years.

Age and chronic hypertension also thicken the arteriolar wall.

Therefore, two scales let the examiner record active and chronic changes independently.

Hypertensive Grades in the Scheie Classification

Therefore, most textbooks use the same sequence:

• First, H0 shows no visible vascular abnormality
• Next, H1 shows diffuse arteriolar narrowing without focal constriction
• Then H2 adds more obvious narrowing with focal constriction
• In addition, H3 shows narrowing plus retinal hemorrhages
• Finally, H4 adds retinal edema, hard exudates and disc edema

Reading Narrowing in Grades 1 and 2

First, grade 1 is the hardest call because no absolute caliber standard exists at the bedside.

Examiners usually judge arteriolar width against the adjacent venule.

However, focal constriction in grade 2 interrupts the smooth column and is easier to see.

Higher Grades: Hemorrhage and Disc Edema

Grade 3 adds retinal hemorrhages, which suggest failing vessel wall integrity.

Then grade 4 adds disc edema, retinal edema and hard exudates.

Also, severe disease can involve the choroid (see hypertensive choroidopathy).

Arteriolosclerosis in the Scheie Classification

The second scale follows the light reflex and arteriovenous crossings:

• First, S0 shows normal arterioles
• Next, S1 shows a broadened light reflex with minimal venous compression
• Then S2 adds a more prominent reflex and crossing changes
• In addition, S3 shows copper wiring with marked crossing changes
• Finally, S4 shows silver wiring with severe crossing changes

Copper and Silver Wiring

Wall thickening alters how the arteriole reflects the ophthalmoscope light.

As the reflex broadens, the vessel takes a copper color.

Next, further thickening obscures the blood column and gives a silver appearance.

However, a silver-wire arteriole may still carry flow.

Arteriovenous Crossing Signs

Arterioles and venules share an adventitial sheath at crossings.

As a result, a thickened arteriole can compress or deflect the venule.

For example, examiners describe Gunn, Salus and Bonnet signs.

In addition, these crossings mark a common site for branch retinal vein occlusion.

Scheie Classification vs Keith-Wagener-Barker

Keith, Wagener and Barker published four combined groups in 1939.

Also, their groups linked higher grades with worse survival in hypertension.

By contrast, the Scheie system separates hypertensive signs from sclerotic signs.

Consequently, it describes a mixed fundus in more detail, for example H1 S3 in an older patient.

Applying the Scheie Classification in Clinic

First, dilate the pupil and examine the posterior pole.

Then assess caliber, focal constriction and hemorrhages for the hypertensive grade.

Next, review the light reflex and crossings for the sclerosis grade.

Finally, record both grades with blood pressure and any macular or disc findings.

Examination Pearls

First, compare both eyes, because marked asymmetry can suggest carotid disease or a vein occlusion.

Then use the green filter to bring out hemorrhages.

Next, remember that cotton wool spots mark nerve fiber layer ischemia.

Imaging and the Scheie Classification

First, fundus photography gives a permanent record for comparison (see fundus photography technique).

Then OCT can confirm macular edema in advanced disease.

In addition, fluorescein angiography shows nonperfusion when the picture is unclear.

Limits of the Scheie Classification

Observer agreement falls in the mild grades, where subtle narrowing drives the score.

Age-related vessel changes also complicate grading.

Therefore, avoid treating a mild grade as a precise measure of systemic risk.

Simpler Modern Grading

Wong and Mitchell proposed mild, moderate and malignant categories based on systemic risk.

Also, malignant disease includes optic disc swelling.

For broader context, see this review of hypertensive retinopathy.

What Changes Management

A grade never replaces systemic assessment, and the physician treats the blood pressure.

However, disc edema with severely elevated pressure needs emergency evaluation for end-organ damage.

In addition, rapid pressure reduction carries ischemic risk, so the medical team should control the rate.

Follow-Up After Grading

First, repeat the examination after blood pressure control, because hemorrhages and exudates can resolve over weeks.

However, arteriolar sclerosis usually persists, so the S grade stays stable.

Therefore, track the H grade for treatment response.

Differential Diagnosis

Similar findings can arise from other conditions:

• For example, diabetic retinopathy with dot hemorrhages
• Also, retinal vein occlusion
• In addition, radiation retinopathy
• Finally, papilledema from raised intracranial pressure

Counseling Patients

First, explain that the retina offers a direct view of small blood vessels.

Also, make clear that a grade cannot predict an individual outcome.

However, new blurred vision or headache with very high readings requires urgent assessment.

Pitfalls to Avoid

• Therefore, name the scale whenever you report a grade
• Also, never mix Scheie grades with Keith-Wagener-Barker groups
• Never attribute disc edema to hypertension without measuring blood pressure
• Avoid overcalling narrowing from a single undilated view

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References

1. Scheie HG. Evaluation of ophthalmoscopic changes of hypertension and arteriolar sclerosis. Arch Ophthalmol. 1953;49:117-138.
2. Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: their course and prognosis. Am J Med Sci. 1939;197:332-343.
3. Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004;351:2310-2317.
4. Walsh JB. Hypertensive retinopathy: description, classification, and prognosis. Ophthalmology. 1982;89:1127-1131.