In younger patients, irregular narrowing of the retinal arterioles is seen, and is thought by many to be because of spasm of the vessel walls. This hypertonicity leads in time to more permanent changes in the vessel walls so that the vessels resemble those of an older patient. Nipping of the veins at arteriovenous crossings is seen and on the distal side of the crossing the vein can be distended. Occasional flame haemorrhages, cottonwool spots and exudates might indicate more severe vascular damage but do not necessarily lead to "malignant" hypertension (Figure 21.11).
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