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The Role of Vision Providersin Stroke Preventionby Mark G. Condell, O.D.
It's been just 40 years since Hollenhorst first suggested a correlation between the "bright plaques in the retinal arterioles" and atheromatous carotid artery disease. Hollenhorst reported that among 235 patients with occlusive disease within the carotid arterial system, 27 or 11% had from a single to several dozen bright, orange-yellow plaques situated at various bifurcations of some of the retinal arterioles.
Hollenhorst states in an article published in a 1961 issue of the Journal of the American Medical Association that, "It is probable that these bright plaques are embolic crystals of cholesterol arising from ulcerating atherosclerotic lesions situated on the cardiac valves or in the endothelium of tha aorta or carotid arteries."
In conclusion, Hollenhorst writes, "It is suggested, although not confirmed pathologically, that these plaques are cholesterol crystals or liquid cholesterol dislodged from eroded atheromatous lesions in the aorta or the innominate, carotid, or ophthalmic arteries. When such lesions are seen in the retinal arterioles, the examiner routinely should palpate and auscultate the carotid arteries, and should refer the patient for investigation of the cardiovascular system." Logic would imply that multiple emboli shower "downstream" into other branches of the arterial system. What travels to the retinal vasculature will also travel to the cerebral vasculature.
Eleven years later, in a subsequent study published in a 1973 issue of the American Journal of Ophthalmology, Hollenhorst reports a 65% mortality rate among 208 of the original group known to have retinal cholesterol emboli.
As a tribute and a legacy to Dr. Hollenhorst, the retinal cholesterol embolus is commonly known as the "Hollenhorst Plaque".
DiscussionStroke from any cause represents the third leading cause of death in the United States. Over 700,000 strokes occur each year, resulting in approximately 165,000 deaths. Stroke is also the leading cause of serious long-term disability in the U.S. The direct and indirect cost of stroke in the United States for 2006 is estimated to be $57.9 billion.
Stroke is a cardiovascular disease. Eighty-eight percent of all strokes are due to arterial occlusion causing ischemia; the remainder are mostly due to hemorrhage. Embolization from ulcerated atherosclerotic lesions at the bifurcation of the common carotid artery is considered the most common mechanism causing ischemic strokes.
The risk of stroke increases with age, and in the presence of hypertension, diabetes, smoking, atrial fibrillation, obesity, hyperlipidemia, and elevated homocysteine level.
Ninety percent of all extracranial carotid lesions are due to athersoclerosis.
In view of the high prevalence of hypercholesterolemia and the aging population in the United States, physicians and vision providers must be alert to the risk factors that may be uncovered during a well-performed history.
Risk Factors for StrokeVision providers who encounter a patient with any of the below risk factors must carefully inspect the retinal vasculature. Ophthalmoscopy plays an important role in the evaluation of these individuals since the eye is the only place where one can directly view blood vessels.
It is the duty of the physician and the vision provider who encounter a patient with any type of retinal emboli to make the appropriate and immediate referral for evaluation of risk for imminent stroke.
Risk Factors for Stroke
Sources: Hollenhorst, RW, Significance of Bright Plaques in the Retinal Arterioles, JAMA. 1961 Oct 7; 178:23-29. Hollenhorst, RW, Morbidity and Survivorship of Patients with Embolic Cholesterol Crystals in the Ocular Fundus, AM J Ophthalmol. 1973 Jan; 75(1):66-72. American Stroke Association: www.strokeassociation.org / American Heart Association: www.americanheart.org.
Published by SafeGuard Health Plans, Inc. March 2006. |
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