Hollenhorst plaques: retinal manifestations and the role of carotid endarterectomy

Role of the physical examination in the determination of etiology of ischemic stroke

The actual investigation of the body of a patient by the clinician in search for the signs of the disease beginning with the primary vital signs and continues with the careful and attentive observation of the patient. This article reviews the key findings in the physical examination of patients with ischemic stroke that have the potential to indicate the etiology of the infarct and to help to choose the use of ancillary tests. Through a systematic search of articles published in English related to the physical examination of patients with stroke, we identified key findings in the vital signs and classic components of the physical exam (appearance of the patient, auscultation, and eye examination) that have shown clinical significance when determining ischemic stroke etiology. We further suggest that the prompt identification of such findings can translate into better use of diagnostic tools and selection of ancillary confirmatory tests, thus, reducing the time to etiology based treatment and secondary prevention of ischemic stroke. in this manuscript, we aim to show that even though nowadays the clinical skills tend to be overlooked due to the overreliance on technology, the physical exam continues to be a valuable tool in the clinician armamentarium when facing the challenge of a patient with ischemic stroke.

Retinal emboli

Retinal emboli are opacities identified in retinal arterioles and are often incidental findings on ophthalmic examination. They are generally composed of cholesterol, platelet-fibrin, or calcium and are thought to arise from carotid arteries, coronary arteries, or cardiac valves. In the general population, the estimated prevalence is 0.2% to 1.3%, and the estimated incidence is 0.9% to 2.9%. The transient nature of retinal emboli likely explains the variations between and within these reported figures. The strongest risk factor for retinal emboli is smoking, which has been reported consistently across many studies. Other likely risk factors include older age, hypertension, male sex, total cholesterol, coronary artery disease, and history of coronary artery bypass grafting. The presence of multiple risk factors, as is common in many patients, confers a higher risk for retinal emboli. Several studies suggest that retinal emboli predict an increase in stroke-related, all-cause, and possibly cardiovascular mortality. Due to these sequelae, patients often undergo further workup, most commonly carotid ultrasonography. However, given the low prevalence of significant carotid disease in patients with retinal emboli, further workup, such as carotid ultrasound, should be reserved for those with risk factors for carotid disease. All patients would benefit from medical optimization and coordinated care with the primary care physician.

A potential pathway for managing diabetic patients with arterial emboli detected by retinal screening

OBJECTIVE

The aim was to review a pathway of care for diabetic patients found to have retinal artery emboli detected by retinal screening.

DESIGN

This was a retrospective review of a pathway agreed in 2001 by a multidisciplinary team.

MATERIALS AND METHODS

The prospectively collected Gloucestershire Diabetic Retinal Screening Programme database was reviewed; patients sent for carotid duplex imaging underwent review of their scan results and their casenotes.

RESULTS

The prevalence of retinal emboli was 214 out of 25,299 diabetic patients who had retinal screening (0.85%). Some 200 diabetic patients underwent carotid duplex imaging; 23 had ipsilateral and 2 had contralateral carotid stenosis > 70%. Of these, ten patients underwent carotid endarterectomy without any major morbidity.

CONCLUSIONS

[corrected] A pathway was established for the small number of patients with retinal emboli, and could be tested in other populations.

A retrospective review of the management of asymptomatic retinal emboli identified during diabetic retinopathy screening: a case of inappropriate referral?

Background

Diabetic retinopathy screening generates many referrals of diabetic patients to ophthalmic clinics for incidental non-retinopathy pathology such as asymptomatic retinal emboli. Evidence exists that these patients have a 10 fold increased relative risk of stroke. With this in mind we evaluated our current management for this group.

Methods

A retrospective review was conducted for patients referred by the screening programme to the Eye Clinic, Derbyshire Royal Infirmary in 2008. Data were collected on modifiable cardiovascular risk factors, investigations conducted and treatment decisions.

Results

Nineteen patients were identified with asymptomatic retinal emboli: nine (47%) had known vascular disease; 13 patients (68%) were taking anti-platelet agents and 11 (58%) a statin. The mean blood pressure (BP) was 152/81 mmHg, but 10 patients (53%) had a BP > 140 mmHg and 47% were on antihypertensive medication. Carotid Doppler scans were performed on eight patients (42%), of whom two (25%) had stenosis over 70%. No new medications such as aspirin were started, nor any alteration made to anti-hypertensive medication.

Conclusion

As the eye clinic visit resulted in no change to the patients’ management, we feel that it may be more appropriate to refer these patients to a medical clinic to optimise their stroke risk reduction management. Br J Diabetes Vasc Dis 2010; 10:126—129

The fate of patients with retinal artery occlusion and Hollenhorst plaque

OBJECTIVE

Ocular symptoms and signs often herald hemispheric neurological events associated with extracranial cerebrovascular disease. However, the presence of a Hollenhorst plaque (HP) or retinal artery occlusion (RAO) and the risk of stroke is unclear. The purpose of this study was to review the outcomes of all patients who presented with a HP or RAO at a single institution.

METHODS

Between 2000 and 2005, the management and outcome of 130 consecutive patients with a diagnosis of HP, central RAO, or branch RAO (ICD-9 codes 362.30 to 362.33) were reviewed. Patients with transient monocular visual loss (amaurosis fugax), retinal venous occlusion, and other ocular pathologies were excluded. Electronic and hardcopy medical records were reviewed for demographic data, clinical variables, radiological, and noninvasive vascular lab testing. Duplex and magnetic resonance angiography (MRA) of the carotid arteries were reviewed to confirm the presence of a lesion and quantify the degree of stenosis.

RESULTS

During the study interval, 70 males and 60 females, with a mean age of 68 +/- 16 (+/-SD) years underwent ophthalmologic evaluation. Symptoms were present in 61% of patients and included eye pain, blurred vision, or atypical visual symptoms, while 39% were asymptomatic. Atherosclerotic risk factors in this population included the presence of hypertension (73%), diabetes (33%), hyperlipidemia (75%), and tobacco use (38%). A majority of patients underwent carotid interrogation via Duplex imaging (68%). Carotid bifurcation stenoses ipsilateral to the ocular findings were <30% in 68% of the patients, between 30 and 60% in 22% and >60% in only 8% of patients. Six patients with lesions greater than 60% went on to have either a carotid endarterectomy or carotid stenting. Follow-up data on this group ranged from 1 to 49 months (median, 22 months), with no stroke or transient ischemic attack identified. There were five deaths during follow-up; none related to stroke. Serial carotid Duplex examinations failed to identify progression of carotid stenoses in this group of patients. Overall survival was 94% at 36 months for this cohort.

CONCLUSION

The presence of a HP or RAO is associated with a low prevalence of extracranial cerebrovascular disease that requires intervention. Furthermore, in contradistinction to amaurosis fugax, these ocular findings are not associated with a high risk for hemispheric neurological events.

Carotid endarterectomy for ophthalmic manifestations: is it ever indicated?

Four ophthalmic manifestations make up a substantial proportion of the indications for carotid endarterectomy (CE). They include transient monocular visual loss (TMVL), ocular ischemic syndrome (OIS), retinal artery occlusion (RAO), and asymptomatic Hollenhorst plaque. Critical review of the literature shows that the evidence to support the efficacy of CE in these four settings is tenuous.

Re-evaluation of carotid duplex for visual complaints: who really needs to be studied?

Amaurosis fugax (AF), Hollenhorst plaques, central retinal artery occlusion (CRAO), and nonspecific visual symptoms are all reasons for patient referral for carotid artery evaluation. This study reviews the management of patients with visual signs or symptoms based on their clinical presentation, carotid duplex results, follow-up data, and outcome. We performed a retrospective review of all patients presenting to the Vascular Surgery Clinic between June 1996 and December 2001 for carotid duplex scanning because of the indication of a visual disturbance. A total of 3560 carotid duplex examinations were performed during the study period; 98 were performed for a visual complaint or finding. A total of 11.1% of group 1 (Hollenhorst plaques), 22.2% in group 2 (CRAO), 45% in group 3 (AF), and 9.8% in group 4 (nonspecific visual symptoms) had significant carotid disease and underwent carotid endarterectomy. No patient who underwent screening carotid duplex and did not have surgically correctable disease developed significant carotid disease or symptoms from carotid disease during the study period. Hollenhorst plaques, CRAO, and nonspecific visual complaints are a poor predictor of significant carotid stenosis, while AF had a significantly higher rate of surgically correctable carotid stenosis. Patients with visual signs or symptoms need an initial screening carotid duplex examination. If this does not show surgically correctable disease, patients do not need to return for further examinations unless another indication arises.

Prognostic value of carotid ultrasound lesion morphology in retinal ischaemia: result of a long term follow up

The importance of carotid plaque morphology in the prognosis of retinal ischaemia was investigated in a group of 165 patients followed for 2-7 years (mean 3.3 years). All patients had an initial carotid duplex ultrasound examination, with the results expressed in terms of the degree of stenosis caused by the lesion, and the lesion morphology. Lesions were divided into two groups, (a) combined homogeneous and simple heterogeneous structures, and (b) complex heterogeneous plaques. Complex heterogeneous plaques had a low echo pool within the lesion and/or an irregular surface pattern. A total of 144 (87%) patients were successfully followed, and of these 37 (26%) had cerebrovascular, cardiovascular, or retinal ischaemic events in the follow up period; 14 (10%) cerebrovascular accidents (eight fatal), 17 (12%) myocardial infarctions (10 fatal), two episodes of amaurosis fugax, and one of tunnel vision caused by a retinal embolus were recorded. There was no report of subsequent blindness. The percentage stenosis caused by the carotid lesions, although more severe in the vascular event group, was not significantly different between the groups. However, a significant difference (p < 0.1) was found in the morphological characteristics of the carotid lesions between the groups. Patients who suffered a vascular event in the follow up period had significantly more complex heterogeneous lesions compared with simple heterogeneous/homogeneous lesions, than those patients who remained alive and well. Carotid endarterectomy and antiplatelet therapy were equally distributed between the event and non-event groups. This suggests that the criteria for selection for treatment should be based on the lesion morphology as well as the degree of stenosis.

Amaurosis fugax: is it innocuous?

A 10 year retrospective study of 103 patients with amaurosis fugax was done. Sixty-two patients with symptoms of amaurosis fugax underwent arteriography, which demonstrated ulcerated carotid plaque in 36 and hemodynamically significant stenoses (greater than 75% diameter reduction) in 26. These 62 patients underwent carotid endarterectomy. The other 41 patients who had proven ulcerated plaque (33 patients) or hemodynamic stenoses (eight patients) were not treated surgically and served as a control series. No strokes or deaths occurred in the immediate postoperative period. Follow-up of the 62 operated patients extending to 10 years (mean 4.2 years), revealed one (1.6%) patient with recurrent amaurosis fugax symptoms, two (3.2%) with transient ischemic attacks, and one (1.6%) with a stroke in the operated hemisphere. In the nonoperated group, despite aspirin or warfarin treatment, four (9.7%) patients had ongoing amaurosis fugax symptoms, and two (4.8%) developed transient ischemic attacks that led to carotid endarterectomy. One (2.4%) other patient developed sudden, permanent monocular blindness, and two (4.8%) suffered hemispheric strokes, one of which was fatal. The cumulative morbidity (ongoing ocular or transient ischemic attack symptoms, perioperative and late stroke) in the operated group was 6.4% (four patients), while the cumulative morbidity in the nonoperated group was significantly higher at 21.9% (nine patients) (p = 0.02). When patients present with symptoms of amaurosis fugax and have demonstrable carotid bifurcation disease, carotid endarterectomy is recommended. Amaurosis fugax should be regarded as a harbinger of monocular blindness and stroke.