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MEDICAL RETINA FEATURE STORY
Hollenhorst Plaques
These may be just the tip of the iceberg.
By Charles C. Wykoff, MD, PhD; and Daniel E. Croft, BA
“The good physician treats the disease; the great
physician treats the patient who has the disease.”
–William Osler, MD, one of the Founding
Professors of Johns Hopkins Hospital
Many of our patients are
affected by retinal pathologies that
are merely a manifestation
of a systemic disease.
A
s retina specialists, we have the privilege of caring for patients with blinding diseases every day.
Many of these patients have isolated retinal
pathologies such as age-related macular degeneration or rhegmatogenous retinal detachment. Many of
our patients, however, are affected by retinal pathologies
that are merely a manifestation of a systemic disease,
such as diabetic retinopathy. Indeed, because of the high
metabolic demand of the retina and because the retinal
and choroidal circulations receive proportionally higher
blood flow volumes per unit area than many other tissues, these vascular beds are often affected by systemic
diseases earlier than other parts of the body.
his left eye (Figure 1) with normal filling in his right eye.
Following a discussion of management options, the
patient chose to be evaluated immediately in a local
emergency room. There, the patient was found to have
>90% proximal, left internal carotid artery narrowing
(Figure 2). The patient underwent urgent vascular surgery with left internal carotid endarterectomy (CEA) and
implantation of a xenograft patch. The patient recovered
rapidly and has remained asymptomatic. Four months
following CEA, FA revealed significantly normalized vascular filling of his left retinal circulation (Figure 3).
Case Presentation and Results
An asymptomatic 55-year-old man with 20/20 visual
acuity in both eyes was referred after presenting with
a Hollenhorst plaque in the left eye during a routine
ophthalmic examination. Fluorescein angiography
(FA) revealed significantly delayed vascular filling in
A
Discussion
Hollenhorst plaques were first described in 1961 by
Robert Hollenhorst, MD, who aptly inferred their intraarterial location as indicative of embolic disease, classically
B
Figure 1. Fundus photograph left eye: Hollenhorst plaque (arrow) involving the inferior major retinal arteriole within the optic
nerve head (A). Fluorescein angiograph showing delayed vascular filling of the retinal circulation (1 minute 51 seconds; B).
74 RETINA Today November/December 2013
MEDICAL RETINA FEATURE STORY
A
B
C
D
Figure 2. CT angiogram: Right common, internal, and external carotid circulations are normal (A). Proximal left internal carotid
artery has >90% lumen narrowing (arrow; B). Carotid ultrasound: Right common, internal, and external carotid arteries with
normal vascular flow (C). Left internal carotid artery with significantly reduced vascular flow (D).
A
B
C
Figure 3. External photograph showing scar from carotid endarterectomy (A). Fundus photograph left eye: Stable Hollenhorst
plaque (arrow; B). Fluorescein angiograph showing improved vascular filling of the retinal circulation with complete filling at
52 seconds (C).
related to carotid arterial disease.1,2
Does the presence of a Hollenhorst plaque, whether
symptomatic or asymptomatic, necessitate emergent
evaluation for an embolic source? Certainly the answer
depends on the specific circumstances of each patient.
In the case of a symptomatic Hollenhorst plaque,
urgent embolic evaluation including carotid ultrasound
analysis is probably indicated, as approximately 25% may
have substantial carotid artery stenosis.3 In patients with
moderate to severe carotid artery stenosis, CEA can substantially reduce the risk of subsequent hemispheric cere-
bral vascular accident (CVA). For example, in the North
American Symptomatic Carotid Endarterectomy Trial
(NASCET), patients with transient monocular visual loss
(TMVL), transient ischemic attack (TIA), or nondisabling
stroke and severe carotid stenosis (70% to 99%) were
randomized to CEA or medical management; CEA led to
a 2-year ipsilateral stroke rate of 9% vs 26% for patients
undergoing medical management alone (P = .001).4
Approximately 75% of Hollenhorst plaques seen in
ophthalmic practice are asymptomatic.3 Many studies
have considered the relationship between asymptomatic
November/December 2013 RETINA Today 75
MEDICAL RETINA FEATURE STORY
plaques and the presence of significant carotid artery
stenosis; significant ipsilateral carotid stenosis can be
identified in 5.6% to 9% of such patients.3,5,6 According to
a meta-analysis of 3 randomized controlled trials involving 5223 patients with asymptomatic moderate to severe
stenosis, intervention with CEA may be indicated if the
perioperative risk is low, as risk of subsequent stroke or
mortality can be reduced substantially (relative risk =
0.69, favoring CEA).7
In the presence of a Hollenhorst plaque, one may consider auscultation of the ipsilateral carotid artery with a
stethoscope. The presence of a carotid bruit may signify
a higher risk of significant carotid artery stenosis and may
help predict CVA, myocardial infarction, and death.3,8
Although some studies have identified value in prognostication, others have suggested that the results of carotid
artery auscultation have neither high specificity nor sensitivity, particularly in asymptomatic patients.9
Evidence suggests that both symptomatic and
asymptomatic Hollenhorst plaques may be markers
for significant carotid artery disease, and their presence
indicates risk factor analysis and carotid ultrasonography. If a patient chooses to defer evaluation until a
later time, one may consider documenting that urgent
referral was offered. Just as the tip of an iceberg is only a
small part of the whole underneath the ocean’s surface,
a Hollenhorst plaque may be but a marker for a more
serious systemic situation. n
Charles C. Wykoff, MD, PhD, is a member
of the Retina Consultants of Houston and a
Clinical Assistant Professor of Ophthalmology
at Weill Cornell Medical College, Methodist
Hospital, Houston, TX. He is a member of the
Retina Today Editorial Board. Dr. Wykoff states
that he has no financial interest in any products
mentioned in this article. He can be reached at
[email protected].
Daniel E. Croft, BA, is a senior research assistant with the Retina Consultants of Houston.
1. Hollenhorst RW. Ocular manifestations of insufficiency or thrombosis of the internal carotid artery. Trans Am
Ophthalmol Soc. 1958;56:474-506.
2. Hollenhorst RW. Significance of bright plaques in the retinal arterioles. Trans Am Ophthalmol Soc.1961;59:252-273.
3. Bakri SJ, Luqman A, Pathik B, et al. Is carotid ultrasound necessary in the clinical evaluation of the asymptomatic
hollenhorst plaque? (An american ophthalmological society thesis). Trans Am Ophthalmol Soc. 2013;111:17-23.
4. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325(7):445-453.
5. Bull DA, Fante RG, Hunter GC, et al. Correlation of ophthalmic findings with carotid artery stenosis. J Cardiovasc
Surg (Torino). 1992;33(4):401-406.
6. Wakefield MC, O’Donnell SD, Goff JM, Jr. Re-evaluation of carotid duplex for visual complaints: who really needs
to be studied? Ann Vasc Surg. 2003;17(6):635-640.
7. Chambers BR, Donnan GA. Carotid endarterectomy for asymptomatic carotid stenosis. Cochrane Database Syst
Rev. 2005(4):CD001923.
8. Pickett CA, Jackson JL, Hemann BA, et al. Carotid bruits as a prognostic indicator of cardiovascular death and
myocardial infarction: a meta-analysis. Lancet. 2008;371(9624):1587-1594.
9. Cournot M, Boccalon H, Cambou JP, et al. Accuracy of the screening physical examination to identify subclinical
atherosclerosis and peripheral arterial disease in asymptomatic subjects. J Vasc Surg. 2007;46(6):1215-1221.