Cholesterol (Hollenhorst) Plaque

Case 4:
Cholesterol Plaque

A 71-year-old man presented with a 6-week history of decreased vision in his right eye. The patient, who had hypertension and migraine headaches, had successfully recovered from a stroke that occurred 1 year earlier. His medications included aspirin, 81 mg/d, clopidogrel, atenolol, and furosemide. He also took gabapentin, 300 mg hs, for his migraine headaches. He had a remote history of cigarette smoking.

The patient's corrected visual acuity was 20/40 in the right eye and 20/20 in the left. He was pseudophakic. The rest of his eye examination was unremarkable, except for a cholesterol plaque at the first bifurcation of the inferior retinal blood vessel at the optic disc margin. Sheathing of the vessels could be seen beyond the bifurcation.

A cholesterol (Hollenhorst) plaque is an endogenous retinal embolus. These emboli usually arise from an ulcerated atheromatous plaque in the carotid artery. Cholesterol plaques appear as single or multiple yellow or copper-colored refractile bodies. As was the case in this patient, they do not always obstruct blood flow.

Cholesterol plaques can cause some focal ischemia and, in rare instances, segmental retinal ischemia. Vision is not usually affected, except perhaps transiently, or if a macular branch artery is involved. Often, the plaque breaks apart over time, and the smaller segments move further "downstream" in the vasculature.

No carotid bruits were audible in this patient, and he was referred back to his primary care physician for further systemic evaluation.