Arcus senilis

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Arcus senilis
Other namesarcus adiposus, arcus juvenilis, arcus lipoides corneae, arcus cornealis
Four representative slides of corneal arcus.jpg
Arcus senilis deposits tend to start at 6 and 12 o'clock and progress until becoming completely circumferential. The thin clear section separating the arcus from the limbus is known as the clear interval of Vogt.
Specialty Ophthalmology   OOjs UI icon edit-ltr-progressive.svg
Symptoms Opaque ring in the peripheral cornea
CausesNormal aging, Hyperlipidemia
Differential diagnosis Limbus sign, limbal ring
TreatmentNone
Prognosis Benign condition in elderly, associated with cardiovascular disease for <50 yrs old

Arcus senilis (AS), also known as gerontoxon, arcus lipoides, arcus corneae, corneal arcus, arcus adiposus, or arcus cornealis, are rings in the peripheral cornea. It is usually caused by cholesterol deposits, so it may be a sign of high cholesterol. It is the most common peripheral corneal opacity, and is usually found in the elderly where it is considered a benign condition. When AS is found in patients less than 50 years old it is termed arcus juvenilis. The finding of arcus juvenilis in combination with hyperlipidemia in younger men represents an increased risk for cardiovascular disease.

Contents

Pathophysiology

AS is caused by leakage of lipoproteins from limbal capillaries into the corneal stroma. Deposits have been found to consist mostly of low-density lipoprotein (LDL). Deposition of lipids into the cornea begins at the superior and inferior aspects, and progresses to encircle the entire peripheral cornea. The interior border of AS has a diffuse appearance, while the exterior border is well demarcated. The clear space between the exterior border and the limbus is called the interval of Vogt. [1]

Bilateral AS is a benign finding in the elderly, but it can be associated with hyperlipidemia in patients less than 50 years old. Bilateral AS may also be caused by increased levels of free fatty acids in the circulation secondary to alcohol use. [2]

Unilateral AS can be associated with contralateral carotid artery stenosis or decreased intraocular pressure in the affected eye. As these are serious medical conditions, unilateral AS should be examined by a physician. [3]

Diagnosis

Corneal arcus in a patient age 60 years Corneal arcus.jpg
Corneal arcus in a patient age 60 years

AS is usually diagnosed through visual inspection by an ophthalmologist or optometrist using a slit lamp.[ citation needed ]

Differential diagnoses

Several conditions can have a similar color and appearance.

Other conditions with similar appearance, but differing in color are limbal ring, and Kayser–Fleischer ring.

Treatment

In the elderly, arcus senilis is a benign condition that does not require treatment. The presence of an arcus senilis in males under the age of 50 may represent a risk factor for cardiovascular disease, [5] and these individuals should be screened for an underlying lipid disorder. The opaque ring in the cornea does not resolve with treatment of a causative disease process, and can create cosmetic concerns. [5]

Epidemiology

In men, AS is increasingly found starting at age 40, and is present in nearly 100% of men over the age of 80. For women, onset of AS begins at age 50 and is present in nearly all females by age 90. [1]

Risk factor for cardiovascular disease

AS is not an independent predictor of cardiovascular disease, as demonstrated by a prospective cohort study of 12,745 Danes aged 20-93 followed up for an average of 22 years. [6]

The presence of AS in men less than 50 years old(arcus juvenilis) in combination with an underlying condition causing hyperlipidemia has been shown to significantly increase the relative risk of mortality from cardiovascular disease and coronary artery disease. As demonstrated by a study following 6,069 Americans aged 30-69 for an average of 8.4 years. [7]

The presence of AS in men less than 50 years old (arcus juvenilis) in conjunction with xanthomas on the achilles tendon has been linked to the presence of atherosclerosis in the coronary arteries and aorta by computed tomography. [8]

See also

Related Research Articles

<span class="mw-page-title-main">Cholesterol</span> Sterol biosynthesized by all animal cells

Cholesterol is the principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils.

High-density lipoprotein (HDL) is one of the five major groups of lipoproteins. Lipoproteins are complex particles composed of multiple proteins which transport all fat molecules (lipids) around the body within the water outside cells. They are typically composed of 80–100 proteins per particle. HDL particles enlarge while circulating in the blood, aggregating more fat molecules and transporting up to hundreds of fat molecules per particle.

<span class="mw-page-title-main">Peripheral artery disease</span> Medical condition

Peripheral artery disease (PAD) is a vascular disorder abnormal narrowing of arteries other than those that supply the heart or brain. PAD can happen in any blood vessel, but it is more common in the legs than the arms.

<span class="mw-page-title-main">Hypercholesterolemia</span> High levels of cholesterol in the blood

Hypercholesterolemia, also called high cholesterol, is the presence of high levels of cholesterol in the blood. It is a form of hyperlipidemia, hyperlipoproteinemia, and dyslipidemia.

Dyslipidemia is a metabolic disorder characterized by abnormally high or low amounts of any or all lipids or lipoproteins in the blood. Dyslipidemia is a risk factor for the development of atherosclerotic cardiovascular diseases (ASCVD), which include coronary artery disease, cerebrovascular disease, and peripheral artery disease. Although dyslipidemia is a risk factor for ASCVD, abnormal levels don't mean that lipid lowering agents need to be started. Other factors, such as comorbid conditions and lifestyle in addition to dyslipidemia, is considered in a cardiovascular risk assessment. In developed countries, most dyslipidemias are hyperlipidemias; that is, an elevation of lipids in the blood. This is often due to diet and lifestyle. Prolonged elevation of insulin resistance can also lead to dyslipidemia. Likewise, increased levels of O-GlcNAc transferase (OGT) may cause dyslipidemia.

<span class="mw-page-title-main">Hypertriglyceridemia</span> High triglyceride blood levels

Hypertriglyceridemia is the presence of high amounts of triglycerides in the blood. Triglycerides are the most abundant fatty molecule in most organisms. Hypertriglyceridemia occurs in various physiologic conditions and in various diseases, and high triglyceride levels are associated with atherosclerosis, even in the absence of hypercholesterolemia and predispose to cardiovascular disease.

Hyperlipidemia is abnormally high levels of any or all lipids or lipoproteins in the blood. The term hyperlipidemia refers to the laboratory finding itself and is also used as an umbrella term covering any of various acquired or genetic disorders that result in that finding. Hyperlipidemia represents a subset of dyslipidemia and a superset of hypercholesterolemia. Hyperlipidemia is usually chronic and requires ongoing medication to control blood lipid levels.

The lipid hypothesis is a medical theory postulating a link between blood cholesterol levels and the occurrence of cardiovascular disease. A summary from 1976 described it as: "measures used to lower the plasma lipids in patients with hyperlipidemia will lead to reductions in new events of coronary heart disease". It states, more concisely, that "decreasing blood cholesterol [...] significantly reduces coronary heart disease".

<span class="mw-page-title-main">Familial hypercholesterolemia</span> Genetic disorder characterized by high cholesterol levels

Familial hypercholesterolemia (FH) is a genetic disorder characterized by high cholesterol levels, specifically very high levels of low-density lipoprotein cholesterol, in the blood and early cardiovascular diseases. The most common mutations diminish the number of functional LDL receptors in the liver or produce abnormal LDL receptors that never go to the cell surface to function properly. Since the underlying body biochemistry is slightly different in individuals with FH, their high cholesterol levels are less responsive to the kinds of cholesterol control methods which are usually more effective in people without FH. Nevertheless, treatment is usually effective.

<span class="mw-page-title-main">Axenfeld–Rieger syndrome</span> Medical condition

Axenfeld–Rieger syndrome is a rare autosomal dominant disorder, which affects the development of the teeth, eyes, and abdominal region.

<span class="mw-page-title-main">Lipoprotein(a)</span> Low-density lipoprotein containing apolipoprotein(a)

Lipoprotein(a) is a low-density lipoprotein variant containing a protein called apolipoprotein(a). Genetic and epidemiological studies have identified lipoprotein(a) as a risk factor for atherosclerosis and related diseases, such as coronary heart disease and stroke.

<span class="mw-page-title-main">Pellucid marginal degeneration</span> Degenerative corneal condition

Pellucid marginal degeneration (PMD) is a degenerative corneal condition, often confused with keratoconus. It typically presents with painless vision loss affecting both eyes. Rarely, it may cause acute vision loss with severe pain due to perforation of the cornea. It is typically characterized by a clear, bilateral thinning (ectasia) in the inferior and peripheral region of the cornea, although some cases affect only one eye. The cause of the disease remains unclear.

<span class="mw-page-title-main">Cornea plana 1</span> Medical condition

Cornea plana 1(CNA1) is a congenital disorder that causes the cornea to flatten and the angle between the sclera and cornea to shrink. This could result in the early development of arcus lipoides, hazy corneal limbus, and hyperopia. Cornea plana 1 is an autosomal dominant disorder.

<span class="mw-page-title-main">Limbal ring</span> Dark ring around the iris of the eye

A limbal ring is a dark ring around the iris of the eye, where the sclera meets the cornea. It is a dark-colored manifestation of the corneal limbus resulting from optical properties of the region. The appearance and visibility of the limbal ring can be negatively affected by a variety of medical conditions concerning the peripheral cornea. It has been suggested that limbal ring thickness may correlate with health or youthfulness and may contribute to facial attractiveness. The thickness of the limbal ring varies by pupil dilation - when the pupil is larger, the limbal ring narrows. Some contact lenses are colored to simulate limbal rings.

<span class="mw-page-title-main">Evacetrapib</span> Chemical compound

Evacetrapib was a drug under development by Eli Lilly & Company that inhibits cholesterylester transfer protein. CETP collects triglycerides from very low-density lipoproteins (VLDL) or low-density lipoproteins (LDL) and exchanges them for cholesteryl esters from high-density lipoproteins (HDL), and vice versa, but primarily increasing high-density lipoprotein and lowering low-density lipoprotein. It is thought that modifying lipoprotein levels modifies the risk of cardiovascular disease. The first CETP inhibitor, torcetrapib, was unsuccessful because it increased levels of the hormone aldosterone and increased blood pressure, which led to excess cardiac events when it was studied. Evacetrapib does not have the same effect. When studied in a small clinical trial in people with elevated LDL and low HDL, significant improvements were noted in their lipid profile.

The limbus sign is a ring of dystrophic calcification evident as a "milky precipitate" at the corneal limbus. The corneal limbus is the part of the eye where the cornea (front/center) meets the sclera. Thought to be caused by increased calcium concentration in the blood, this sign however persists after calcium phosphate concentration returns to normal. Compare the limbus sign (calcification) with arcus senilis (lipid).

<span class="mw-page-title-main">Lipidology</span>

Lipidology is the scientific study of lipids. Lipids are a group of biological macromolecules that have a multitude of functions in the body. Clinical studies on lipid metabolism in the body have led to developments in therapeutic lipidology for disorders such as cardiovascular disease.

Testosterone and the cardiovascular system are the effects that the male hormone testosterone has on the cardiovascular system.

Remnant cholesterol, also known as remnant lipoprotein, is a very atherogenic lipoprotein composed primarily of very low-density lipoprotein (VLDL) and intermediate-density lipoprotein (IDL). Stated another way, remnant cholesterol is all plasma cholesterol that is not LDL cholesterol or HDL cholesterol, which are triglyceride-poor lipoproteins. However, remnant cholesterol is primarily chylomicron and VLDL, and each remnant particle contains about 40 times more cholesterol than LDL.

Peripheral Ulcerative Keratitis (PUK) is a group of destructive inflammatory diseases involving the peripheral cornea in human eyes. The symptoms of PUK include pain, redness of the eyeball, photophobia, and decreased vision accompanied by distinctive signs of crescent-shaped damage of the cornea. The causes of this disease are broad, ranging from injuries, contamination of contact lenses, to association with other systemic conditions. PUK is associated with different ocular and systemic diseases. Mooren's ulcer is a common form of PUK. The majority of PUK is mediated by local or systemic immunological processes, which can lead to inflammation and eventually tissue damage. Standard PUK diagnostic test involves reviewing the medical history and a completing physical examinations. Two major treatments are the use of medications such as corticosteroids or other immunosuppressive agents and surgical resection of the conjunctiva. The prognosis of PUK is unclear with one study providing potential complications. PUK is a rare condition with an estimated incidence of 3 per million annually.

References

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  3. Naumann GO, Küchle M (November 1993). "Unilateral corneal arcus lipoides". Lancet. 342 (8880): 1185. doi:10.1016/0140-6736(93)92170-x. PMID   7901520. S2CID   5395741.
  4. Williams ME (2010-06-21). Geriatric Physical Diagnosis: A Guide to Observation and Assessment. McFarland. p. 96. ISBN   978-0-7864-5160-9.
  5. 1 2 Munjal A, Kaufman EJ (2021). "Arcus Senilis". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   32119257 . Retrieved 2021-03-23.
  6. Christoffersen M, Frikke-Schmidt R, Schnohr P, Jensen GB, Nordestgaard BG, Tybjærg-Hansen A (September 2011). "Xanthelasmata, arcus corneae, and ischaemic vascular disease and death in general population: prospective cohort study". BMJ. 343: d5497. doi:10.1136/bmj.d5497. PMC   3174271 . PMID   21920887.
  7. Chambless LE, Fuchs FD, Linn S, Kritchevsky SB, Larosa JC, Segal P, Rifkind BM (October 1990). "The association of corneal arcus with coronary heart disease and cardiovascular disease mortality in the Lipid Research Clinics Mortality Follow-up Study". American Journal of Public Health. 80 (10): 1200–4. doi:10.2105/ajph.80.10.1200. PMC   1404822 . PMID   2400030.
  8. Zech LA, Hoeg JM (March 2008). "Correlating corneal arcus with atherosclerosis in familial hypercholesterolemia". Lipids in Health and Disease. 7: 7. doi: 10.1186/1476-511X-7-7 . PMC   2279133 . PMID   18331643.