Introduction <p>Hypertensive retinopathy reflects systemic vascular damage and serves as an indicator of end-organ involvement among patients with systemic hypertension. Despite its clinical importance, evidence on disease severity and its determinants in low- and middle-income settings, including Northern Ethiopia, remains limited.</p> Objective <p>To assess the severity of hypertensive retinopathy and its determinants among adult patients attending ophthalmic centers in Northern Ethiopia in 2025.</p> Methods <p>A multicenter, institutional-based cross-sectional study was conducted among adult patients with confirmed hypertensive retinopathy attending ophthalmic centers of Amhara region comprehensive specialized hospitals from May 7 to November 7, 2025. Data were collected using KoboToolbox and exported to STATA version 17 for analysis. Bivariable and multivariable ordinal logistic regression analysis were performed to identify factors associated with disease severity of hypertensive retinopathy. Variables with a p-value &lt; 0.05 in the multivariable analysis were considered statistically significant.</p> Results <p>A total of 400 hypertension adults with confirmatory hypertensive retinopathy cases achieving a response rate of 96.62% were involved under the study. History of cataract surgery (AOR = 2.19; 95 CI: 1.32–3.61), Diabetes mellitus (AOR = 1.61; 95% CI: 1.05–2.47), and chronic kidney disease (AOR = 3.16; 95% CI: 1.82–5.48) were significantly associated however regular hypertension check-up (AOR = 0.47; 95% CI: 0.27–0.80) was protective.</p> Conclusion <p>Severity of hypertensive retinopathy were significantly associated with history of cataract surgery, diabetes mellitus and chronic kidney disease while regular hypertension follow-up was protective highlighting the importance of integrated clinical evaluation and routine retinal screening in hypertension patient care.</p>