PURPOSE: Retinal ischemic perivascular lesions (RIPLs), seen on optical coherence tomography (OCT) as localized retinal changes, are markers of subclinical retinal infarcts. RIPLs are linked to systemic cardiovascular diseases, including hypertension and type 2 diabetes. Pulmonary hypertension (PH) stems from diverse etiologies, including cardiac, pulmonary, and thromboembolic causes. This study aimed to assess the relationship between RIPLs and PH, evaluating whether RIPL counts differ between PH and control groups and among PH subtypes. METHODS: This retrospective, cross-sectional study included patients with PH who had undergone retinal imaging within 5 years of diagnosis and controls with a coronary artery calcium score of 0. Retinal imaging was performed using macular OCT scans (Spectralis, Heidelberg Engineering, Franklin, MA). Patients with poor-quality images and significant retinal disease were excluded from the study. Statistical analyses compared clinical variables and RIPL counts among controls, pre-PH, and PH groups, and among PH subtypes. RESULTS: Among 129 patients (65 controls, 18 pre-PH, and 46 PH), pre-PH and PH groups had higher RIPL counts (control = 2.05, pre-PH = 5.78, and PH = 3.93) and prevalence (control = 48%, pPre-PH = 94%, and PH = 70%) than controls. The increased odds of elevated RIPLs in pre-PH and PH were not significant after adjustment. PH from lung disease had lower RIPL counts than other subtypes. CONCLUSIONS: Patients with pre-PH and PH have higher RIPL counts than healthy controls. Differences among PH subtypes suggest RIPLs reflect the impact of systemic vascular disease. TRANSLATIONAL RELEVANCE: RIPLs are associated with systemic microvascular dysfunction and may serve as biomarkers for early disease management and patient stratification.