Roth spots: what is it, causes, symptoms, treatment

What are Roth spots?

Roth spots - White retinal hemorrhages, were first described by Moritz Roth, a Swiss physician in 1872. However, it was not until 1878 that this condition was named "Roth's spot" by Moritz Litten. Litten reported that these white retinal haemorrhages were found in 80% of cases associated with subacute bacterial endocarditis. Roth spots are most often associated with infectious endocarditis. However, they can be seen in a wide variety of conditions, including leukemia, anemia, hypertensive retinopathy, preeclampsia, diabetic retinopathy and anoxia.

Causes

Historically, Roth spots have been considered a pathognomonic sign of bacterial endocarditis secondary to septic retinal emboli. Given the recent histological findings, the spots are now believed to be the result of retinal capillary rupture and intraretinal hemorrhage. Roth spots occur in a variety of painful processes in which retinal blood vessels are damaged and subsequently bleed and hemorrhaged. A common thread found under these conditions is a predisposition to endothelial dysfunction, leading to rupture of retinal capillaries. Histological examination shows that white lesions consist mainly of fibrin, which is a fibrin-platelet plug at the site of the vessel rupture.

Epidemiology

White hemorrhages in the retina in the center is a nonspecific ophthalmic finding observed in multiple systemic conditions of various etiologies. Roth spots are visible on examination of the fundus and, as a rule, are located in the peripheral or posterior poles of the eye. Retinal endothelial dysfunction appears to be a common thread among the various causes of retinal hemorrhage in the white center. Differential diagnosis of Roth spots is extensive and includes:

• bacterial endocarditis;
• anemia/thrombocytopenia;
• collagen vascular diseases;
• leukemia;
• hypertensive retinopathy;
• diabetic retinopathy;
• preeclampsia;
• human immunodeficiency virus (HIV);
• anoxia;
• concussion syndrome.

Pathophysiology

Although many theories have been proposed to explain the pathogenesis of retinal hemorrhages in the center of the white color, the most widespread theory of rupture of retinal capillaries and intraretinal hemorrhage. Rupture of retinal capillaries occurs as a result of endothelial cell dysfunction. The rupture of the vessel is followed by the outflow of erythrocytes, followed by the activation of the coagulation cascade and the formation of a platelet-fibrin plug at the site of the damaged endothelium. Histological studies have shown that proteins are composed mainly of platelets-fibrin.

Signs and physical examination

Retinal hemorrhage is commonly seen in patients with underlying disease processes that predispose to dysfunction and rupture of the retinal endothelium. Roth spots can be seen on routine ophthalmologic examination in asymptomatic patients, prompting further diagnosis and evaluation. However, patients may also present with signs and symptoms of systemic disease and retinal hemorrhage noted during emergency diagnosis. The presence of spots on the physical examination should prompt the physician to evaluate the underlying systemic disease. The doctor must take a thorough history and undergo a thorough physical examination.

A detailed history with a complete overview of the system can help narrow the differential diagnosis and reveal the underlying disease process. Attention should be paid to symptoms associated with the more common etiology of Roth spots. Analyze symptoms of endocarditis and infection, including fever, chills, and night sweats. Symptoms commonly seen with haematological conditions, such as unexplained weight loss, fatigue, abnormal bleeding or bruising, and shortness of breath, should also be evaluated. A review of personal past medical history as well as family history can also be helpful in determining etiology.

Roth spots are visible when examining the fundus. A complete ophthalmologic examination is necessary, as spots may accompany other retinal abnormalities. Once Roth spots are identified, the physician should carefully examine the patient to assess physical signs of systemic disease. It is important to note the vital functions of the patient, especially blood pressure, temperature and pulse. Some etiologies of white retinal hemorrhages are associated with the results of the classical physical examination; therefore, the physician should have a high withdrawal index during the examination. In patients with concerns about endocarditis and Roth spots, the clinician should carefully investigate other signs of endocarditis, including Janeway's rash, Osler's nodules, splinter hemorrhages, petechiae and heart murmur.

Analyzes

All patients should undergo a complete differential blood count to evaluate leukocytosis, anemia and thrombocytopenia, and other hematologic abnormalities. To assess diabetes mellitus, fasting plasma glucose or hemoglobin A1C should be measured. If an infectious etiology is suspected erythrocyte sedimentation rate C-reactive protein and blood culture may be indicated. A transthoracic echocardiogram is an important initial diagnostic test for suspected endocarditis. Additional tests should be considered, such as HIV antibody testing, imaging studies or a peripheral blood smear if indicated on the basis of symptoms and signs of physical survey.

Treatment

Roth spots are most often asymptomatic and are found during routine examination of the dilated eyes. Visual impairment due to Roth spots is rare, but can occur with macular lesions. Most white retinal haemorrhages resolve without intervention. Treatment is directed at the underlying cause and is often supportive. The most important aspect of the management of patients with Roth spots is to determine the causal etiology for prevention of possible ocular and systemic complications that may arise due to the main diseases. Follow-up by an ophthalmologist is an important aspect for patients with spots found during an acute illness.