Ophthalmic considerations Hyperlipidemia is a significant risk factor for ischemic heart disease, cerebrovascular disease, and peripheral arterial disease. The ophthalmologist may be the first physician to detect or recognize manifestations of atherosclerosis, particularly transient monocular visual loss, retinal vascular emboli or occlusions, ischemic optic neuropathy, or cortical visual field deficits from a previous cerebral infarction. Detection of atherosclerosis may initiate a diagnostic evaluation that reveals significant carotid artery stenosis or coronary artery disease.

Corneal arcus, a nonreversible lipid deposit at the corneal limbus, is associated with age and hyperlipidemia. In the Blue Mountains Eye Study, the presence of arcus in persons aged 49 years and older was associated with higher total cholesterol and triglyceride levels.

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial was designed to assess the effect of tight glycemic, dyslipidemic, and blood pressure control on cardiovascular events in patients with type 2 diabetes. A subset of these patients (ACCORD EYE) was examined to assess the effects of this control on the progression of diabetic retinopathy (DR). Previous studies had shown mixed results of the effect of tight glycemic control on DR. In the ACCORD EYE study, the tight control of glycemia resulted in a 33% reduction in the relative risk of progression of DR, although it did not decrease the risk of moderate vision loss. Treating patients with simvastatin plus fenofibrate for dyslipidemia control yielded a 40% reduction in the risk of DR progression. Tight blood pressure control did not appear to affect DR progression in ACCORD. Previous studies (eg, the Fenofibrate Intervention and Event Lowering in Diabetes [FIELD] study) have also suggested a possible protective effect of the use of fenofibrate on DR.

Statin use may also be associated with a reduction in intraocular pressure and potentially a protective effect against glaucoma. Additional clinical research is needed. Patients with ocular hypertension or glaucoma being treated with topical timolol have a small but statistically significant elevation of serum LDL and reduction in HDL, but do not appear to have increased mortality.

The relationship of statin use to age-related macular degeneration (AMD) is unresolved. Several population-based studies (Atherosclerosis Risk in Communities [ARIC], the Melbourne Collaborative Cohort Study, Blue Mountains Eye Study) have suggested that the use of statins is associated with a decreased risk of advanced AMD, whereas other studies (Beaver Dam, Age-Related Eye Disease Study 2 [AREDS2]) suggest there is no change in AMD risk with statin use. More data are required to assess the nature of this relationship.

The effect of statins on the development of cataracts is unclear. Although the Blue Mountains study suggested a protective effect, the AREDS2 study points to an increased risk of cataract development in patients taking a statin, particularly in women over age 75.

• Al-Holou SN, Tucker WR, Agron E, et al; Age-Related Eye Disease Study 2 Research Group. The association of statin use with age-related macular degeneration progression: The Age-Related Eye Disease Study 2 Report Number 9. Ophthalmol. 2015; 122(12):2490–2496.

  Al-Holou SN, Tucker WR, Agron E et al; Age-Related Eye Disease Study 2 Research Group. The association of statin use with cataract progression and cataract surgery: The AREDS2 Report Number 8. Ophthalmol. 2016; 123(4):916–917.

  American Academy of Ophthalmology website; www.aao.org.

  American Heart Association website; www.heart.org.

  CardioSource. American College of Cardiology website; www.acc.org.

  Chew EY, Ambrosius WT, Davis MD, et al; ACCORD Study group, ACCORD Eye Study group. Effects of medical therapies on retinopathy progression in type 2 diabetes. N Engl J Med. 2010; 363(3):233–244.

  European Society of Cardiology website; www.escardio.org.

  Talwar N, Musch DC, Stein JD. Association of daily dosage and type of statin agent with risk of open-angle glaucoma. JAMA Ophthalmol. 2017; 135(3):263–267.

  Tan JS, Mitchell P, Rochtchina E, Wang JJ. Statin use and the long-term risk of incident cataract: The Blue Mountains Eye Study. Am J Ophthalmol. 2007;143(4):687–689.