As a primary care optometrist, the majority of my patients every day are scheduled for routine comprehensive exams.  It's time to update their glasses and contact lens prescriptions; no significant vision or pain complaints. I'm a strong believer that at every routine exam we should also do an ocular health assessment, even when the patient has no complaints about their eyes or vision. Unfortunately the eye is a body part that isn't very good at telling us when something is wrong.  Most blinding conditions of the eye, and most systemic conditions that steal sight have absolutely no symptoms -- no pain, no vision changes -- until you are permanently blind.  I know you and I wouldn't want to wait that long to find them.  I want to share this real case from my practice as a great example about why routine health care should always include dilation and/or retinal imaging.  This patient and his team of medical doctors are very happy that he didn't skip the dilation or imaging this year.

The Case:
47 year old white male presents for routine eye exam with no vision complaints.  Only known medical condition is hyperthyroidism, for which he takes levoxyl.  He had LASIK a few years ago and is 20/20 in both eyes without any glasses prescription required.  All ocular health is normal, even his eye pressure (11 and 10 mmHg in right and left eye respectively).  But then we look at his retinal imaging and we see this:

Right Eye:


Left Eye:


To the untrained eye, the multiple hemorrhages in these photographs might be hard to spot.  The photos below have been color and brightness enhanced to better visualize the bleeding going on in the retina:

Right Eye:


Left Eye:


Both eyes have multiple intraretinal hemorrhages scattered throughout.  The most obvious can be seen inferiorly on the right eye photograph -- they look like red blotches in the retina.  Whenever we find bleeding in the eye, the usual culprit is a systemic vascular condition.  High blood pressure and diabetes are two common systemic conditions that cause retinal hemorrhages.  But this patient had never been diagnosed with any vascular condition, and he saw his primary care doctor regularly. Blood work was ordered and the results came back with elevated white blood cell count.  Further testing confirmed the diagnosis: chronic myeloid leukemia.

Chronic myeloid leukemia (or CML) is a cancer of the bone marrow, disrupting the body's ability to make platelets, red blood cells, and white blood cells.  In the chronic stage of this cancer, most patients are completely asymptomatic.  They might feel fatigue or joint pain, but our patient had neither complaint.  Luckily with treatment the chance for survival with CML is very good.  A 2011 study of Gleevic found a survival rate of  95.2% of treated patients after 8 years.  With early intervention, the treatment has even better chances for success.  Interestingly, only 5-10% of patients with CML present with ophthalmic signs or symptoms at initial diagnosis, but those that do have retinal hemorrhaging or other associates retinal findings like optic nerve edema have a lower 5 year survival rate:  21.4% compared to 45.7% of those without.   That's why finding signs like retinal bleeds and getting the proper blood work is so essential  -- if the signs are there but aren't caught, the patient has a much lower chance of survival.  But if these signs are found during routine eye exams, the patient can get treatment much faster and earlier in the disease process, and improve their chance for survival!

This case is a great story about how routine health care is the best way to protect your health. Whenever you are tempted to blow off your annual exam, or skip that dilation because it's not convenient, think about that possibility that today's eye exam could save your life.

1. The most obvious ocular health concern that you'll spot is at the macula.  See those yellow color distortions right in the center?  Those are drusen consistent with dry age related macular degeneration.  This patient came in for her annual exam with a known history of AMD that was being followed, so this macular appearance was expected.  But can you see the new issue?

2. Follow the artery (the lighter colored blood vessel) up from the optic nerve and you'll come to a whitish round circle smack in the middle of the artery wall.  This is a cholesterol plaque lodged in the arteriole, called a Hollenhorst plaque.  Luckily you can see blood passing through the artery to the other side.  If the blood vessel is white on the other side of the artery we know we have full obstruction and this would be an artery occlusion instead of just a plaque (occluded arteries are much more serious!).  A cholesterol plaque, even when there is blood passing around it, is still a potentially serious threat to vision and systemic health; if there's a blockage in your eye there is likely a risk for cholesterol blockages elsewhere too.

What You Need to Know
Cholesterol blockages or Hollenhorst plaques are often found without causing any vision symptoms, so this is just one more reason why routine ocular health checks with dilation or imaging is a vital part of everyone's preventative health care.  The patient above had absolutely no vision complaints, and unless blood flow is being blocked, likely there will be no affect on vision. If there is a plaque limiting blood flow to the retinal tissue, the patient will likely experience blacking out of vision (called amaurosis fugax or transient ischemic attacks) that can last for minutes at a time. Any sudden vision loss is always worth a call to your eye doctor, even when it is painless!

via

There is no active treatment for Hollenhorst plaques in the exam chair, but finding the cause of the blockage is the first line of action. Studies suggest between 45-55% of patients with Hollenhorst plaques have significant carotid stenosis (blockage) of the internal carotid artery on the same side as the affected artery.  Your doctor will order a carotid doppler or ultrasound to detect the presence of stenosis.  If you have been diagnosed with conditions like high cholesterol, high blood pressure, diabetes, or are a smoker you are at a much higher risk of getting these cholesterol blockages due to chronic damage to your artery walls. The carotid artery is particularly at risk for cholesterol plaque blockage because it splits into multiple branches right as it enter the base of the skull.  The split into smaller passageways creates an area for cholesterol plaques to get lodged, constricting blood flow through the area.  The carotid artery is very dangerous to occlude though -- it's delivering blood not just to your eye but to your brain so a blockage here could put you at risk for serious health issues and even a stroke.

If your doctor finds carotid stenosis on your ultrasound, it will likely be treated with oral medications like anti-platelet/blood thinners (baby aspirin is a common one) and cholesterol lowering medication like the statin category of meds.  Surgical treatment is sometimes required to remove the obstruction -- typically when the carotid is > 60% stenosed surgery is the preferred treatmetn method. 

Optos retinal imaging showing a Hollenhorst plaque via

By The Numbers
While you might not notice any problems or changes in your vision, if a Hollenhorst plaque is found during your eye exam it's not to be taken lightly.  The Beaver Dam Eye Study found that those with Hollenhorst plaques or any retinal emboli were at a 3 x higher risk of fatal stroke over the next 8 years.  This is a finding not to be ignored, and just another reason that when you go to your eye doctor, you need to have retinal imaging and or dilation done every single year, even if you don't notice any problems with your vision.  An eye exam is a snapshot of your entire systemic health, and using the retina like a window into your body's inner workings can save your life.