Optometry case study: Transient visual loss

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by Giles Campbell, optometrist, Specsavers North Lakes, Australia

History
• A 56 year old male presented c/o blurring in the inferior nasal
quadrant of the left eye for 3 days which then resolved but
returned again after 1 week.
• GH – hypertensive
• POH – none
• FOH – none

Examination
• Best corrected visual acuity RE 6/6
LE 6/7.5
• Amsler – blurring inferior nasal corner left eye
• IOPs R 13mm Hg, L 12mm Hg
• See left eye digital retinal photo

Provisional diagnosis
• Hollenhorst plaque lodged at bifurcation of superior temporal artery.

Referred to ophthalmologist for further investigation
• Confirmed diagnosis and requested following tests:
• Carotid artery ultrasound
• Fasting blood sugar
• Cholesterol

Discussion
A Hollenhorst plaque is a cholesterol embolus seen in a retinal artery.

Signs and symptoms
• Bright yellow/ white plaque often seen at a retinal arteriole bifurcation.
• These plaques tend to break up and move and may not be seen at subsequent visits.
• Patients may be asymptomatic or experience transient episodes of
partial or complete monocular visual loss (amaurosis fugax).

Aetiology
• The embolus is composed of cholesterol often from an ulcerated ipsilateral carotid artery plaque.
• Associated with hypertension and hypercholesterolaemia.
• If blood flow is sufficiently impaired retinal ischemia can result in the tissue distal to the blockage.

Management by optometrist/ ophthalmologist
• The emboli themselves require no treatment as blood can often flow through an apparently complete blockage.
• Retinal embolus indicates significant systemic vascular disease.
• Refer to GP for further investigation / possible onward referral.

Investigations / treatment
• Carotid ultrasound
• Fasting glucose and lipids
• Blood chemistry with cardiac enzymes
• Treat underlying vascular disease
• Treat carotid stenosis if required (carotid angioplasty)
• Aspirin therapy

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