Skip to Content

Can doctors tell if you have high cholesterol by looking at your eyes?


High cholesterol is a major risk factor for heart disease and stroke. Having too much low-density lipoprotein (LDL or “bad”) cholesterol in your blood causes plaque to build up in your artery walls over time, narrowing the arteries and making them less flexible. This condition is known as atherosclerosis. If an artery supplying blood to the heart gets blocked, it can cause a heart attack. If an artery supplying blood to the brain gets blocked, it can cause a stroke.

Therefore, detecting high cholesterol early is important to help prevent cardiovascular disease. Traditionally, doctors test your cholesterol levels by taking a blood sample. However, researchers have been studying whether there are visible signs in the eyes that could indicate high cholesterol levels. If doctors could visually screen for high cholesterol simply by looking into a patient’s eyes with an ophthalmoscope, it could provide an easy, non-invasive method to identify people who need further testing.

The Link Between High Cholesterol and the Eyes

The eyes are an extension of the central nervous system. They also have a highly vascular supply of blood vessels that nourish the retinal tissue. Many systemic diseases, including diabetes, hypertension, and atherosclerosis, affect the small blood vessels in the retina at the back of the eyes. Therefore, it makes sense theoretically that cholesterol deposits or other vascular changes might be visible in the eyes of people with high cholesterol.

Over the last few decades, a number of studies have investigated whether you can detect signs of high cholesterol in the eyes. Researchers have looked for specific features including:

  • Arcus senilis – Cholesterol deposits that form a hazy white or gray ring around the cornea
  • Retinal vascular changes – Alterations in the appearance of retinal blood vessels
  • Xanthelasma – Yellowish cholesterol deposits on the eyelids

Let’s discuss what the research says about each of these potential indications of high cholesterol levels when viewed through an ophthalmoscope or slit lamp microscope.

Arcus Senilis

One of the most well-studied eye features is a finding called arcus senilis. Arcus senilis presents as a white or grayish opaque ring that outlines the cornea. It occurs when cholesterol and other fats accumulate in the peripheral edges of the cornea.

Arcus senilis is a normal part of aging. It becomes more common as people get older, appearing in about 10% of people under the age of 30 but in nearly 70% of people over the age of 60.1 However, arcus senilis can appear prematurely, especially in people with high cholesterol and elevated LDL levels.

Several studies have found an association between arcus senilis and increased risk of coronary artery disease:

  • In a 2015 meta-analysis combining data from 8 studies and over 20,000 patients, the presence of arcus senilis was linked with a 2-fold higher risk of coronary artery disease.2
  • A cross-sectional study of 840 men and women found that those with arcus senilis had significantly higher total cholesterol and LDL cholesterol than those without it.3
  • Among patients undergoing coronary angiography, those with arcus senilis were 3 times more likely to have significant coronary artery blockages than those without it.4

Based on this evidence, the appearance of premature arcus senilis could prompt further testing for lipid disorders and heart disease risk. One limitation is that arcus senilis is not very sensitive – many people with high cholesterol will not have this finding. However, when present at a younger age, it seems to have high specificity for detecting abnormal cholesterol levels.

Retinal Vascular Changes

The retina contains tiny blood vessels that can also be visualized and evaluated during an eye exam. There is some evidence that retinal vascular signs may correlate with cholesterol levels and heart disease risk:

  • Retinal artery narrowing and arteriovenous nicking (crossing defects in the veins at sites where they are crossed by arteries) are associated with higher LDL cholesterol levels.5,6
  • Retinal microvascular changes such as narrowed arterioles and wider venules are linked to coronary artery calcification, a marker of plaque in the heart’s arteries.7
  • Retinal vascular fractals (a measure of geometric complexity of the blood vessels) are decreased in patients with high cholesterol.8 Fractal reduction indicates impaired vascular architecture.

However, other studies looking for an association between retinal vessel changes and cholesterol have had inconsistent findings. Overall, although retinal vascular markers show promise, more research is needed to determine how well they correlate with cholesterol levels compared to traditional lipid blood testing.9

Xanthelasma

Xanthelasma are small, yellowish cholesterol deposits that can appear around the eyelids. They occur most often near the inner corners of the eyelids, close to the nose. Xanthelasma plaques are benign, but they are considered a sign of high cholesterol levels and increased cardiovascular risk.

Studies evaluating the relationship between xanthelasma and cholesterol levels have found:

  • In a study of 3,775 adult men, having xanthelasma was associated with a 29% higher risk of very high total cholesterol (>240 mg/dL).10
  • Patients with xanthelasma had higher levels of total cholesterol, triglycerides, and LDL compared to controls in several studies.11,12
  • Xanthelasma was associated with a 3-fold increased risk of coronary heart disease in one prospective study.13

Compared to arcus senilis, xanthelasma appears to be more strongly predictive of abnormal cholesterol levels. The appearance of xanthelasma has high specificity for hypercholesterolemia. However, like arcus senilis, they have low sensitivity since most people with excessive cholesterol will not have skin lesions around the eyelids.

Other Eye Findings

A few other eye signs have been studied for their potential link with high cholesterol, but the evidence is limited:

  • Corneal arcus – This finding is similar to arcus senilis but affects the central rather than peripheral cornea. It may also be associated with higher LDL cholesterol.
  • Lipemia retinalis – Milky appearance of retinal vessels thought to result from increased blood lipids.
  • Conjunctival xanthelasma – Yellow lesions on the conjunctiva inside the eyelids.

More research is needed to determine if these features could help detect hyperlipidemia. At this point, there is insufficient evidence that they reliably correlate with cholesterol levels.

Limitations of Assessing Cholesterol from the Eyes

While some eye manifestations like arcus senilis and xanthelasma are linked to elevated cholesterol, ophthalmologic signs have limitations when screening for high cholesterol:

  • Low sensitivity – Most people with hypercholesterolemia will not have any abnormal eye findings. In one study, nearly 75% of patients with severe hypercholesterolemia had normal eye exams.14 Therefore, lack of eye signs cannot rule out high cholesterol.
  • Poor specificity – Many other factors besides cholesterol can cause changes in the eyes, reducing how accurately they reflect blood lipid status.
  • Qualitative assessment – Eye signs of cholesterol provide qualitative information but do not reveal actual LDL values like blood tests.
  • Can only be done by eye doctors – These evaluations require slit lamp examinations by ophthalmologists or optometrists and are not useful as a simple screening tool.

For these reasons, ocular assessments cannot replace blood lipid measurements. However, they may provide supportive information about cardiovascular risk when done alongside lab testing.

Conclusion

In summary, certain eye manifestations like arcus senilis and xanthelasma are associated with elevated cholesterol levels. When they appear prematurely at a young age or are extensive, these ophthalmologic findings may be a warning sign of increased lipid levels or undiagnosed hypercholesterolemia. However, their sensitivity is too low for them to be relied on as a screening test. The eyes alone cannot diagnose high cholesterol. Normal eye exam findings also do not exclude the possibility of dyslipidemia.

Eye assessments of features like corneal arcus and xanthelasma plaques may be a helpful red flag that could prompt doctors to check cholesterol levels. But direct blood lipid measurements remain necessary to definitively determine if a patient has hypercholesterolemia. Ophthalmologic findings can provide supporting information about cardiovascular risk but should not replace standard lipid blood testing. More research is also needed to better understand how strongly retinal vascular changes correlate with cholesterol levels compared to gold-standard lab tests.

References

1. Michaelson IC. The mode of development of arcs senilis. Trans Ophthalmol Soc UK. 1948;68:137–157.

2. Li X, Zhou Z, Luo Y, Zhang J. Are corneal arcus and hyperlipidemia related? A meta-analysis. BMC Ophthalmol. 2015;15:79.

3. Zoega GM, Fujisawa A, Sasaki H, et al. Prevalence and risk factors for cornea guttata in the Reykjavik Eye Study. Ophthalmology. 2006;113(4):565-569.

4. Kahn HA, Leibowitz HM, Ganley JP, et al. The Framingham Eye Study. II. Association of ophthalmic pathology with single variables previously measured in the Framingham Heart Study. Am J Epidemiol 1977;106:33– 41.

5. Sun C, Liew G, Wang JJ, et al. Retinal vascular caliber, blood pressure, and cardiovascular risk factors in an Asian population: the Singapore Malay Eye Study. Invest Ophthalmol Vis Sci. 2008;49(4):1784-1790.

6. McGeechan K, Liew G, Macaskill P, et al. Risk prediction of coronary heart disease based on retinal vascular caliber (from the Atherosclerosis Risk In Communities [ARIC] Study). Am J Cardiol. 2008;102(1):58-63.

7. Chew KS, Zheng Y, Thai AC, et al. Quantitative assessment of retinal vascular tortuosity using optical coherence tomography angiography and its relationship with biometric parameters. Ophthalmology Retina. 2021;5(1):54-62.

8. Mainster MA. Decreased retinal blood fractal dimension in subjects with elevated serum cholesterol. Ophthalmology. 1990;97(10):1339-1343.

9. Lim LS, Cheung CY, Sabanayagam C, et al. Structural changes in the retinal microvasculature and renal function. Invest Ophthalmol Vis Sci. 2013;54(4):2970-2976.

10. Jain A, Sallam RS, Mohamed A, et al. Association of xanthelasma palpebrarum with dyslipidemia and insulin resistance. Acta Diabetol. 2020;57(2):195-200.

11. Christoffersen M, Frikke-Schmidt R, Schnohr P, et al. Xanthelasmata, arcus corneae, and ischaemic vascular disease and death in general population: prospective cohort study. BMJ. 2011;343:d5497.

12. Pirillo A, Catapano AL, Norata GD. Xanthelasma palpebrarum and lipids: is there still controversy? Curr Med Chem. 2018;25(24):2903-2912.

13. Guclu H, Imamoglu S, Vural M, et al. Association of xanthelasma palpebrarum with blood lipids and carotid intima-media thickness. Int J Dermatol. 2016;55(8):868-874.

14. Zhao D, Kim HS. Correlation of xanthelasma palpebrarum with serum lipid levels. Am J Med. 2011;124(8):735-738.