Cardiovascular disease and stroke continue to be the chief causes of death in developed countries and one of the leading causes of visual impairment. The individual with systemic hypertension may remain asymptomatic for many years. Systemic mortality and morbidity are markedly higher for hypertensives than normotensives, but can be significantly reduced by early diagnosis and then efficient management. However, the ability of Optometrists to detect and appropriately refer systemic hypertensives remains generally poor. This review examines the disease, its effects and detection by observation of the retinal signs, particularly those considered to be pre-malignant. Previous methods of classifying retinal hypertensive signs are discussed along with more recent image analysis techniques. The role of the optometrist in detecting, monitoring and appropriate referral of systemic hypertensives is discussed in relation to current research. (C) 2001 The College of Optometrists. Published by Elsevier Science Ltd. All rights reserved.