Retrospective Review of Incidental Retinal Emboli Found on Diabetic Retinopathy Screening: Is There a Benefit to Referral for Work-Up and Possible Management?

With the rising utilization of diabetic retinopathy photography screening programs across the country, many clinical and socioeconomic questions remain. For the most part, diabetic retinopathy findings have standard follow-up and referral guidelines.1 However, management of other pathology, such as retinal arteriolar emboli, in this patient population is less clear.The association of these lesions with cerebrovascular and cardiovascular morbidity and mortality has been well described in the literature.2,3 Retinal emboli are associated with a higher risk of stroke4 and, as shown by a pooled analysis of two large, population-based studies, predict a modest increase in all-cause and stroke-related mortality independent of cardiovascular risk factors.5Retinal emboli have been identified in 1.3-1.4%6,7 of individuals > 40 years of age. These are plaque-like lesions wedged within retinal arterioles. They are oval- or rhomboid-shaped and have either a reflective or nonreflective appearance.8,9 Reflective emboli are composed of cholesterol crystals, whereas nonreflective types consist of fibrin, platelets, and calcium.10 Cholesterol emboli, also known as Hollenhorst plaques, are the most common, accounting for about 80%.7,11 There are various sources for retinal arteriolar emboli. It is thought that cholesterol emboli ulcerate from atheromatous internal or common carotid plaques, platelet-fibrin emboli arise from mural thrombus in the carotid, and calcific emboli originate from cardiac valvular structures.12,13The relationship between diabetes and retinal emboli is not well characterized. Of the two large studies that have examined retinal emboli—the Beaver Dam Eye Study (BDES)6 and the Blue Mountains Eye Study (BMES)7—only the BDES found that subjects with retinal emboli had a higher prevalence of diabetes than when compared to those patients without retinal emboli.Because retinal arteriolar emboli are associated with a higher risk of stroke and …