Peter G Swann
A fifty-year old Chinese male reported to our Clinic for a routine eye examination. He complained of poor near vision with his reading glasses. Long distance vision was described as clear. There were no headaches and general health was good with no medications being taken. His personal ocular history and family ocular history was unremarkable.
Unaided vision was R 6/5 L 6/5. The pupils were equal and round with no relative afferent defects. The anterior eyes were normal with slit-lamp examination and IOP was R 15 L 15mmHg (NCT at 10am). Confrontation visual fields were normal. Ophthalmoscopy revealed a yellow, glistening plaque at a retinal arteriolar bifurcation about one disc diameter superior-nasal to the right optic disc, (Figure 1). There was no evidence of retinal ischaemia distal to the plaque. The remainder of the ophthalmoscopic examination of each eye gave normal findings.
The patient was referred to his GP without delay.
These bright yellow plaques in the retinal arterioles are cholesterol emboli and are known as Hollenhorst plaques, named for the American ophthalmologist, Robert Hollenhorst, who first described them and their significance in detail in 1961. They typically originate from an atheromatous ulcerated plaque in the internal carotid artery where turbulence in the blood flow causes pieces of the material to break off and enter the retinal circulation. They usually lodge at a bifurcation and only occasionally fully block the arteriole. Therefore, they are often discovered during routine ophthalmoscopy in asymptomatic patients. Alternatively, there may be symptoms of amaurosis fugax, (episodes of temporary monocular vision loss) or transient ischaemic attacks, and a history of systemic difficulties such as hypertension and diabetes. With time the emboli may break up and move on. Their refractile nature frequently makes them appear larger than the calibre of the vessel that contains them.
Finding Hollenhorst plaques is very important as 15% of these patients succumb to a heart attack or stroke within a year. Immediate referral to the patient’s GP will enable an appropriate specialist investigation. Treatment modalities include antiplatelet therapy with, for example, asprin, cholesterol lowering medications and carotid artery surgery.
Hollenhorst RW. Significance of bright plaques in the retinal arterioles. JAMA 1961; 178: 23-29.
Peter Swann was until 2006 Associate Professor in the School of Optometry at the Queensland University of Technology (QUT) in Brisbane where he had been a faculty member for 36 years. His main teaching interests were diseases of the eye, clinical methods of eye examination and paralytic strabismus. Professor Swann has lectured and published extensively in these areas both nationally and internationally. Presently he is a sessional academic at QUT, and Visiting Professor in the School of Optometry at The Hong Kong Polytechnic University.