To evaluate the present role of fundal examination in the assessment of the hypertensive patient, 348 hypertensive subjects, mostly with borderline or mild hypertension, were studied with direct ophthalmoscopy. The exam was always performed by the same observer. The degree of left ventricular hypertrophy was also evaluated with ECG and echocardiography. Blood pressure was measured with 24-hour ambulatory monitoring, using either the Del Mar Avionics Pressurometer II and IV, the Spacelabs 5200 or the A & D TM-2420. Signs of hypertensive retinopathy were found in 51% of the subjects. The degree of retinopathy, defined according to a modified Keith-Wagener grading system, was highly correlated with average 24-hour mean blood pressure (r = 0.31; p less than 0.0001). Based on ECG, 16% of the subjects had left ventricular hypertrophy, while 23% showed an echocardiographic left ventricular mass, indexed by body surface area, above the normal limits. Left ventricular mass index was correlated with ambulatory blood pressure levels, but at a lower level of statistical significance (r = 0.19; p less than 0.001) compared to the degree of retinopathy. No correlation was found between 24-hour blood pressure and ECG findings. Ophthalmoscopy proved to be more sensitive than echocardiography and ECG in indexing 24-hour blood pressure load, while the specificity of the 3 exams was similar. The present data indicate that fundal examination is a sensitive indicator of the vascular consequences of increased blood pressure and is therefore useful in the assessment of the hypertensive patient, while the more expensive echocardiography is not of great clinical value in borderline and mild hypertension.