Snap Shot A 55-year-old black man with a five year history of essential hypertension has a retinal examination revealing irregular caliber of the arterioles, copper wiring, focal areas of arterio-venous nicking, and cotton wool spots. No flame hemorrhages are present. Introduction Focal spasms followed by progressive sclerosis and narrowing of retinal vessels Results in flame hemorrhage from vessel rupture, formation of exudates, and papilledema Presentation Symptoms vision loss Physical exam tortuous retinal veins and venous microaneurysms Evaluation Retinal examination copper wiring means blood is still passing thorugh silver wiring means the vessel is obliterated cotton wool exudates reflect microinfarction hard exudates reflect protein leakage AV nicking caused by arterioles that cross over veins hardening papilledema