Figure 1. Cholesterol emboli (Hollenhorst plaques) comprise 80 percent of retinal plaques. In this patient case, a second Hollenhorst plaque was noted at an artery bifurcation along the superior temporal arcade. Image courtesy Jade Coats, OD
Cardiovascular events and heart disease make up the number-one cause of death in the United States. Stroke is the fifth most common cause of death in the U.S. with nearly 80 percent of all strokes caused by occlusion of a vessel secondary to embolus or atherothrombosis.1
Previously by Dr. Coats: Blog: A case of demodex infestation with eyelash extensions
Case history
A 74-year-old male presented for his routine annual exam with no visual complaints. After monovision cataract surgery, he subjectively saw well at both distance and near, with a best corrected visual acuity of 20/20 at distance and near.
In his chief complaint, the patient mentioned a short episode that had occurred a few weeks prior in which he noticed a “pink tint” to his vision while playing golf. Other than that, however, he reported no other known visual disturbances.
The anterior segment was unremarkable other than mild dry eye disease. Upon dilated evaluation, a small resolving branch retinal vein occlusion (BRVO) was noted along the superior temporal artery in the mid-periphery of the right eye.
A shiny, almost prismatic, Hollenhorst plaque was found upstream to the BRVO at an adjacent artery bifurcation. Because this BRVO was not in the vicinity of the macular area, the patient was able to still see well and did not experience any decline in vision.
A second Hollenhorst plaque was also noted as a artery bifurcation along the superior temporal arcade (See Figure 1).
Related: Visual outcomes of branch retinal artery occlusions effected by early detection
Now what?
Although having a carotid artery doppler is recommended within the first two weeks of noticing plaques, I tend to refer for an evaluation more urgently.
If the patient is exhibiting multiple new plaques or retinal occlusions, especially paired with previous subjective visual disturbances, I recommend within one week, if possible.
Because this patient had multiple newly documented emboli plaques, an occlusion in the same eye, and an increased in-office blood pressure (160/80), I decided to refer to his primary-care practitioner (PCP) for a blood workup including fasting blood glucose (FBS)/glycated hemoglobin (A1C), complete blood count (CBC), lipid profile, and an emphasis on the need for a carotid artery evaluation and ultrasonography.
Patients with these findings typically end up needing a full cardiac workup, as well as hypercoagulable testing such as antiphospholipid antibodies and homocysteine levels.
Related: Involve primary-care doctor in retinal artery occlusion
1. Kaufman EJ, Patel BC. Hollenhorst Plaque. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan.
2. Chawluk JB, Kushner MJ, Bank WJ, Silver FL, Jamieson DG, Bosley TM, Conway DJ, Co-hen D, Savino PJ. Atherosclerotic carotid artery disease in patients with retinal ischemic syndromes. Neurology. 1988 Jun;38(6):858-63.
3. Bakri SJ, Luqman A, Pathik B, Chandrasekaran K. Is carotid ultrasound necessary in the clinical evaluation of the asymptomatic Hollenhorst plaque? Trans Am Ophthalmol Soc. 2013;111:17-23.
4. Hollenhorst RW. Vascular status of patients who have cholesterol emboli in the retina. Am J Ophthalmol. 1966 May;61(5 Pt 2):1159-65.
