Eye Exam Saves Patient's Life

[EyeGotIt]

The following article is from a newsletter from the practice I worked at last summer. It shows how much more optometrists do than just prescribe glasses or contacts.

"Recently one of NSVC's patients came in for his annual comprehensive eye examination. He was a healthy 59 year-old gentleman we had cared for during the past 10 years. His reason for visit was to possibly strengthen the prescription in his reading glasses, but he did mention that over the past week he had experienced episodes of dimming central vision in his right eye (without pain) lasting about two to three minutes.

Being quite concerned, Dr. Eiden carefully examined the condition of the patient's retinal blood vessels (both with Optomap retinal imaging followed by three-dimensional microscopic examination). The doctor noticed a very small off-white plaque located within one of the retinal arteries. This finding, along with the patient's symptoms suggested the possibility of carotid artery obstruction.

The patient was immediately referred to his internist for diagnostic testing utilizing Doppler ultrasonography of the carotid arteries. Findings indicated over 98 percent obstruction of the right carotid and 85 percent for the left. The patient then underwent surgery to open blood flow in his right carotid artery and was placed on blood thinner medications. He is expected to have a normal life from this point on. He fortunately avoided a devastating or potentially lethal stroke."

http://www.nsvc.com/newsletter/2007-01.htm#2

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[MariaMaria]

Very nice of you for sharing this. Thank you!

 

[Eyedoc1999]

I had this exact same situation a few years back. Pt came in with symptoms of TIAs (transient ischemic attacks - in her case, blacking out of vision caused by blockages in blood flow) so I dilated her and found a plaque in one of her retinal vessels (called a hollenhorst plaque) and sent her for a stat eval w/internal medicine. They did doppler and she was 98% and 92% blocked and they got her into surgery that same day. If they hadn't she would have had a fatal stroke in the not very distant future.

Another episode three months ago. Pt comes in with complaints of recent onset blurry vision. Dilated exam reveals a branch retinal vein occlusion indicating out of control BP. I asked if he had hypertension and he said no, so naturally I checked it myself and he was 250/135. I had him transported to the internal medicine doctor a block away and after a quick triage he was admitted to the hospital and as of last week he is controlled. He was a heart attack/stroke waiting to happen quickly also.

 

[in_translation]

these types of stories are some of the best - they remind me why i'm in this.
thanks for sharing!

 

[ODhopeful]

I had this exact same situation a few years back. Pt came in with symptoms of TIAs (transient ischemic attacks - in her case, blacking out of vision caused by blockages in blood flow) so I dilated her and found a plaque in one of her retinal vessels (called a hollenhorst plaque) and sent her for a stat eval w/internal medicine. They did doppler and she was 98% and 92% blocked and they got her into surgery that same day. If they hadn't she would have had a fatal stroke in the not very distant future.

Another episode three months ago. Pt comes in with complaints of recent onset blurry vision. Dilated exam reveals a branch retinal vein occlusion indicating out of control BP. I asked if he had hypertension and he said no, so naturally I checked it myself and he was 250/135. I had him transported to the internal medicine doctor a block away and after a quick triage he was admitted to the hospital and as of last week he is controlled. He was a heart attack/stroke waiting to happen quickly also.

One of my attending recently mentioned that the whole perception of Hollenhorst plaque is a piece plaque that chipped off some big blockage is being overturned. I think they're saying that there's no correlation b/t the two, but again I just heard my attending and he could be wrong.

 

[Eyedoc1999]

One of my attending recently mentioned that the whole perception of Hollenhorst plaque is a piece plaque that chipped off some big blockage is being overturned. I think they're saying that there's no correlation b/t the two, but again I just heard my attending and he could be wrong.

OK, I'll bite...where did the damn thing come from and why do carotid ultrasounds ALWAYS confirm the partial to complete blockages when they are present? I think it's fair to say that not all blockages end up in the retinal vasculature, but if it's there it came from somewhere. I've not seen a lot of them, but I've NEVER had one that didn't have significant blockages in the carotids.

 

[IndianaOD]

If I have one noted in my patient chart, you better believe they are getting a carotid doppler. CYA - all the way!

 

[Caffeinated]

OK, I'll bite...where did the damn thing come from and why do carotid ultrasounds ALWAYS confirm the partial to complete blockages when they are present? I think it's fair to say that not all blockages end up in the retinal vasculature, but if it's there it came from somewhere. I've not seen a lot of them, but I've NEVER had one that didn't have significant blockages in the carotids.

Always is a pretty strong term. If it were truly ALWAYS, then you wouldn't need the Doppler, you could just call the vascular surgeon and have them book the OR date. One study from the early 90s showed that 18% of asymptomatic patients with retinal emboli had common or internal carotid stenosis of 75% or more. Other studies from the 90s showed that about 20% of patients with retinal emboli had stenosis of 50% or more.

Retinal emboli may also originate from the aorta, either spontaneously or as a result of cardiac catheterization or CABG.

 

[Eyedoc1999]

Always is a pretty strong term. If it were truly ALWAYS, then you wouldn't need the Doppler, you could just call the vascular surgeon and have them book the OR date. One study from the early 90s showed that 18% of asymptomatic patients with retinal emboli had common or internal carotid stenosis of 75% or more. Other studies from the 90s showed that about 20% of patients with retinal emboli had stenosis of 50% or more.

Retinal emboli may also originate from the aorta, either spontaneously or as a result of cardiac catheterization or CABG.

Was there a point to your post other than to try to be arguementative? It is a strong term...because it's a fact. Given that I'm not a vascular surgeon and they would need a quantative justification for surgery, you WOULD need the doppler. I also didn't say they are always blocked to the point of surgery, I simply said that there is ALWAYS some amount of blockage requiring monitoring at the very least if not some sort of therapeutic/surgical intervention. In order to properly monitor, you need to establish a baseline of which doppler would be part.

FWIW, if they had a cardiac cath, that would be an explanation for the emboli but I would still refer back for ultrasound. From a legal perspective, how quickly do you think you would be found guilty of malpractice if your patient had a stroke and there was listed in your chart a retinal embolus on which you didn't order follow up? I'll give you a hint...I hope your watch has a second hand.

 

[Caffeinated]

Was there a point to your post other than to try to be arguementative? It is a strong term...because it's a fact. Given that I'm not a vascular surgeon and they would need a quantative justification for surgery, you WOULD need the doppler. I also didn't say they are always blocked to the point of surgery, I simply said that there is ALWAYS some amount of blockage requiring monitoring at the very least if not some sort of therapeutic/surgical intervention. In order to properly monitor, you need to establish a baseline of which doppler would be part.

FWIW, if they had a cardiac cath, that would be an explanation for the emboli but I would still refer back for ultrasound. From a legal perspective, how quickly do you think you would be found guilty of malpractice if your patient had a stroke and there was listed in your chart a retinal embolus on which you didn't order follow up? I'll give you a hint...I hope your watch has a second hand.

Not trying to be argumentative at all. I agree that Doppler is clincally indicated in the case of an otherwise asymptomatic retinal embolus. I simply wanted to highlight that the differential for a retinal embolus has to be broader. The #1 in my differential would be definitely be carotid atherosclerotic disease. I cite the above studies to highlight 1) that retinal emboli are not always indicative of a high-grade carotid stenosis, and that 2) there are other etiologies of retinal emboli to consider in the differential.