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Midlife retinopathy predicts ischemic stroke

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Technology to the rescue

The findings are really not surprising. Retinal microvascular changes are a sign of end-organ damage. Small-vessel disease in the eye, small-vessel disease in the brain. This makes a lot of sense.

The question is: Which magic wand do we need to be able to measure and calculate these changes? These are not changes you are going to be able to detect easily when looking at the ocular fundus with your ophthalmoscope. These are very subtle changes we are taking about.

There’s new technology, like optical coherence tomography, and this is what will save us. People are working to provide us tools to automatically calculate retinal microvascular changes from fundus photographs. I have no doubt that within the next 2-3 years we will be able to use this technology. We are almost there; we are in the hands of engineers.

Valerie Biousse, MD , is a professor of neuro-ophthalmology at Emory University, Atlanta. She had no relevant disclosures.



– The more severe retinopathy is at midlife, the greater the risk of ischemic stroke – particularly lacunar stroke – later on, according to investigators from Johns Hopkins University, Baltimore.

Retinopathy has been associated with strokes before, but the investigators wanted to see whether it could predict stroke type. The idea is that microvascular changes in the retina could mirror microvascular changes in the brain that could lead to stroke.

The positive findings mean that “retinal microvasculature may serve as a biomarker for cerebrovascular health. Retinal imaging may enable further risk stratification of cerebrovascular and neurodegenerative diseases for early, intensive preventive interventions,” said lead investigator Michelle Lin, MD, a stroke fellow at Johns Hopkins.

A full evaluation is beyond the scope of a quick ophthalmoscope check up in the office. The advent of smartphone fundoscopic cameras and optical coherence tomography – which provides images of retinal vasculature at micrometer-level resolution – will likely help retinal imaging reach its full potential in the clinic, she said at the annual meeting of the American Academy of Neurology.

Dr. Lin and her team reviewed 10,468 participants in the Atherosclerosis Risk in Communities Study database. They had baseline retinal photographs from 1993-1995 when they were 45-65 years old. The photos were checked for four types of retinopathy: arteriovenous nicking, focal arteriolar narrowing, retinal microaneurysms, and retinal hemorrhage. The presence of each one was given a score of 1, yielding a retinopathy severity score of 0-4, with 4 meaning subjects had all four types.

Over a median follow-up period of 18.8 years, 578 participants had an ischemic stroke, including 114 lacunar strokes, 292 nonlacunar strokes, and 172 cardioembolic strokes. Hemorrhagic strokes occurred in 95 subjects.

The incidence of ischemic stroke increased with the severity of baseline retinopathy, from 2.7 strokes per 1,000 participant-years among those with no retinopathy to 10.2 among those with a severity score of 3 or higher (P less than .001). The 15-year cumulative risk of ischemic stroke with any retinopathy was 3.4% versus 1.6% with no retinopathy (P less than .001).

After adjustment for age, sex, race, comorbidities, and other confounders, retinal microvasculopathy associated positively with ischemic stroke, especially lacunar stroke (adjusted hazard ratio, 1.84; 95% confidence interval, 1.23-2.74; P = .005).

Trends linking retinopathy severity to the incidence of nonlacunar, cardioembolic, and hemorrhagic strokes were not statistically significant. Factors associated with higher retinopathy grade included older age, black race, hypertension, and diabetes, among others.

There were slightly more women than men in the review. The average age at baseline was 59 years. Patients with stroke histories at baseline were excluded.

The work was funded by the National Institutes of Health. The investigators had no disclosures.

SOURCE: Lin MP et al. Neurology. 2018 Apr;90(15 Suppl.):CCI.001.

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