Objective:

To discuss the appropriate responses of optometrists to high blood pressure, Hollenhorst plaques, and other vascular findings as presented by Drs. Rothstein and Swanson.

Approach:

• Blood Pressure Measurement: A single office blood pressure measurement may not represent a patient’s usual pressure, with variability averaging 12 mmHg and reaching 32 mmHg at higher systolic pressures due to factors such as an unsupported back, recent smoking, a full bladder, pain, and the clinical setting.
• Distinction of Hypertension Types: Severe asymptomatic hypertension is distinguished from hypertensive emergencies, which involve blood pressure above 180/120 mmHg with new or progressive target-organ damage, necessitating emergency referral for concerning systemic symptoms or retinal findings.
• Retinal Examination: Retinal findings such as arteriolar narrowing, arteriovenous nicking, and hemorrhages inform the urgency of referrals and further assessments, with specific classifications for hypertensive retinopathy.
• Retinal Artery Occlusion (RAO): RAO is classified as a stroke, with CRAO occurring at an estimated rate of 2 cases per 100,000 person-years, and presenting with sudden, painless vision loss.
• Management Recommendations: Immediate referral to a stroke center is recommended for RAO onset within 72 hours, while urgent outpatient work-up is suggested for later presentations, provided there are no red flags.
• Hollenhorst Plaques: Asymptomatic Hollenhorst plaques require cardiovascular evaluation, while symptomatic plaques necessitate immediate assessment and referral to the patient’s primary care physician.
• Transient Ischemic Attack (TIA): Patients with TIA symptoms within 48 hours should be sent directly to the emergency department and alert the stroke team.

Key Findings:

• Blood pressure readings can vary significantly and may not reflect true hypertension.
• Retinal findings can indicate chronic disease or acute emergencies.
• CRAO is a significant risk factor for concurrent brain strokes, particularly in the first 2 weeks.
• Hollenhorst plaques are often asymptomatic but require cardiovascular evaluation.

Interpretation:

The presentation emphasizes careful assessment and timely referral in cases of vascular findings in the retina.

Limitations:

• Normal blood work does not rule out conditions like giant cell arteritis.
• The effectiveness of thrombolysis in CRAO remains uncertain, with recent trial results described as inconclusive.

Conclusion:

Optometrists must recognize retinal signs that indicate vascular emergencies and respond accordingly.

Sources:

• Central retinal artery occlusion: a stroke of the eye
• Ocular vascular occlusive disorders: natural history of visual outcome
• Ischemic stroke risk in Medicare beneficiaries with central retinal artery occlusion