Occasionally, the primary-care OD may encounter a Roth spot, or a white centered hemorrhage. Classically associated with bacterial endocarditis, leukemia and anemia, these lesions are actually linked to a myriad of systemic conditions, often leaving the provider wondering what tests should be ordered or what systemic work-up is needed.
The following is a case of a patient who presented with a Roth spot and the subsequent management.
A 55-year-old male presented to the clinic for a comprehensive eye exam with a chief complaint of blurry vision at distance and near with his habitual bifocal glasses.
His pertinent medical history included hypertension and type 2 diabetes mellitus for approximately 10 years. He had been on medications for his diabetes previously but was taken off a few years ago; he now controled his diabetes with diet and exercise.
Incoming acuities were 20/20 OU with correction. Pupils were normal with no afferent pupillary defect, extraocular muscles were full OU, and full to finger counting on confrontation OD and OS. Slit-lamp examination of the anterior segment was unremarkable OU, and intraocular pressures (IOP) were 18 mm OD, OS.
Dilated examination showed normal vessel caliber OU, rim tissue was pink and healthy, and margins were distinct OU with cup-to-disc ratio of 0.35 rd OU. Posterior pole revealed a few small dot blot hemorrhages OU with a solitary white centered hemorrhage in the inferior temporal arcade OD. Based on clinical appearance (Figure 1), it was diagnosed as a classic Roth spot.
Based on retinal findings, labs were ordered, including a complete blood count (CBC) and diabetes panel. Lab results showed an elevated A1c at 7.4 percent (normal range 4.2 to 5.8), glucose was also high at 137 mg/dL (normal range 70 to 110 mg/dL), and monocyte percentage was slightly elevated at 10.9 percent (normal range 2.0 to 10 percent). All other findings were normal.
His blood pressure was measured in-office as 131/84 mm Hg. The patient had a recent echocardiogram, performed approximately six months previously, which was normal per physician note. The patient was referred back to his primary-care physician who re-initiated oral treatment for his diabetes and discussed ways to lower the patient’s blood pressure.
The patient returned for dilated fundus examination (DFE) follow-up visit three months later with no subjective complaints. Upon dilated examination, the white centered hemorrhage had completely resolved. The patient also continued to deny fever, shortness of breath, or recent infections.
Based on the review of systems, lack of acute symptomology, medical history, and lab test results, it was determined the isolated white centered hemorrhage was likely associated with the patient’s diabetes. The patient was scheduled for a six-month return visit.
A Roth spot is any round to slightly oval hemorrhage with a solitary, homogenous, paler, round center completely surrounded by the hemorrhage.1
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