Dear Dr. Roach: During my recent visit with my optometrist, a retinal embolus (a Hollenhorst plaque) was discovered in my right eye. It was stated that this embolus could possibly dislodge, travel to my brain and cause a stroke. A carotid ultrasound didn’t show a problem with the blood flow there. Now I am waiting to get a referral with a retinal specialist, which will take four to six weeks.
I am a 77-year-old very active male in excellent health. My cholesterol is always in the range of 160 mg/dL. I am 5 feet, 10 inches tall and weigh 175 pounds. The only medications that I take are omeprazole for GERD and terazosin for my prostate. I had successful cataract surgery on that same eye last November, and there wasn’t any indication of this embolus during my last visit for this surgery. What is the probability of my having a stroke? Should there be restrictions on my activities while I wait for more testing?
D.S.
Most people know an embolus as a blood clot that travels from a large blood vessel until it gets lodged in a smaller blood vessel, where it can completely stop the blood from flowing, causing cell death.
However, there are other types of emboli. Air can get into the blood system and cause an air embolus, but your case consists of a cholesterol embolus, which usually comes from a cholesterol plaque in the heart or the large vessels, like the aorta or the carotid arteries. The optometrist can diagnose a cholesterol embolus by sight — that’s what a Hollenhorst plaque is.
You don’t need to worry about what they found going somewhere else. The concern is that the same source of cholesterol could send another embolus to your eye (which can cause vision loss), or to a different part of your brain (which can cause a stroke), or to another critical organ (the kidneys are often affected by cholesterol emboli and can be damaged by many of these).
To reduce that risk, your regular doctor or cardiologist should consider what’s best for you. Almost everyone with a history of cholesterol emboli should be on lipid-reducing therapy. Statin drugs, in particular, have been shown to stabilize the plaque, even if the blood cholesterol is in the desirable range.
Aspirin and some blood pressure medicines also may be prescribed. You shouldn’t wait six weeks for that — see your regular doctor or a specialist. Obviously, smoking must stop, and diabetes should be controlled, if appropriate. Your doctor may consider noninvasive tests on your heart.
I recommend avoiding any kind of medical procedure and extreme exercise until you have had a more thorough evaluation.
Dear Dr. Roach: What does it mean to prescribe a medicine “off label”? Is this fraudulent? Can a doctor get in trouble for this?
A.S.
The U.S. FDA approves drugs for specific medical indications, but it is frequent that after approval, a medicine may be found useful for other medical problems — different from the one it was originally approved for.
Sometimes, a drug company will petition to add an approved indication, but other times, prescribers use these drugs for other conditions when there is evidence of effectiveness. For example, interferon alpha was initially approved only for use in patients with a rare disease called hairy cell leukemia, but it was found to be very useful for many other diseases.
It’s important for both researchers and clinicians to have medications available outside of their specific indications, but physicians who do so need to be careful to prescribe based on evidence. I prefer results from well-done clinical trials, but a physician’s own experience is valid as well.
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