White-centred retinal haemorrhages (Roth spots)

Abstract

SummaryRoth spots (white-centred retinal haemorrhages) were classically described as septic emboli lodged in the retina ofpatients with subacute bacterial endocarditis. Indeed many have considered Roth spots pathognomonic for this condition. More recent histological evidence suggests, however, that they are not foci of bacterial abscess. Instead, they are nonspecific and may be found in many other diseases. A review of the histology and the pathogenesis of these whitecentred haemorrhages will be provided, along with the work-up of the differential diagnosis. How is it that such diverse conditions produce retinal haemorrhages of the same morphology? Excluding patients with systemic sepsis, it is inconceivable that the white centres in all the other cases represent infected embolic foci of septic infiltrates. Furthermore, with the exception of patients with leukaemia, it is difficult to imagine that these lesions represent a concentration of leukocytes. Conditions in which RothThe answer lies in a closer histological examination of the white centre of the Roth spot. Histopathology of the Roth spotEarly investigators were surprised by the lack of definite aggregations of bacteria and leukocytes in the white centre of the lesions in specimens of patients who died of sepsis.4 Instead, they observed areas within the lesions where cellular staining is faint and the endothelium of capillaries becomes indefinite and shows hyaline changes. These histological observations were inconsistent with the proposed explanation of a bacterial abscess as the white centre of a Roth spot. Recent investigators have given prominence to the presence of fibrin in the lesions. Wong and Bodey had noted fibrin in their aplastic anaemia patients.' Von Barsewisch observed in perinatal retinal haemorrhages that the electron microscopic appearance of white-centred haemorrhages corresponds to fibrin fibrillae and concluded that the white centre of Roth spot represents a fibrin thrombus at the site of a vessel rupture.6 Duane et al confirmed the observation of the fibrin and platelet aggregate in the white centre of Roth spots in leukaemic patients and further alluded to the fact that the haemorrhage in one leukaemic eye came from a centrally located aneurysm, with 'symmetrical distribution of fibrin, platelets and infiltrating red blood cells' arising from the aneurysm.7The pathogenesis of Roth spots: a unifying theory White-centred haemorrhage may thus result from the rupture 6f retinal capillaries and the extrusion of whole blood. Subsequent platelet adhesion to damaged endothelium and the platelet release reaction initiates the coagulation cascade on 11 April 2019 by guest. Protected by copyright.

Autoimmune Hemolytic Anemia: Mixed Type—A Case Report

“…Roth spots are found in a variety of medical conditions other than IE and profound anemia is one of them. Ischemic insults to capillary endothelium of any etiology associated with elevated venous pressures can cause roth spots and retinal haemorrhages and as such is a non specific sign [14]. One case of AIHA associated with IE has been published, however roth spots have not been reported [8].…”

Multiple retinal haemorrhages (decompression retinopathy) following paracentesis for macular branch artery occlusion

“…1,2 These white centred haemorrhages are observed in a variety of conditions, including ocular decompression. [3][4][5] Conditions that lead to an altered clotting state, capillary trauma, capillary endothelium ischaemia, or an increase in capillary fragility may lead to retinal haemorrhages. 3 Following paracentesis for acute angle closure glaucoma, no observed cases of decompression retinopathy were noted and it was suggested that a vasculopathy may be required to predispose a patient to decompression retinopathy.…”

“…[3][4][5] Conditions that lead to an altered clotting state, capillary trauma, capillary endothelium ischaemia, or an increase in capillary fragility may lead to retinal haemorrhages. 3 Following paracentesis for acute angle closure glaucoma, no observed cases of decompression retinopathy were noted and it was suggested that a vasculopathy may be required to predispose a patient to decompression retinopathy. 6 In our case, the possibility of capillary fragility from an inherited or acquired abnormality is possible, but despite extensive investigation no systemic cause for the artery occlusion was found.…”

Decompression Retinopathy after Trabeculectomy

“…[8][9][10][11][12][13] Usually retinal capillaries are impermeable 14 but certain conditions such as those listed above can result in anoxic insult or sudden elevation of venous pressure, thereby rupturing the thin capillary wall in multiple foci and resulting in multiple, white-centered hemorrhages. 15 Retinal hemorrhages after glaucoma surgery are relatively rare.…”