Early investigators thought the white centers represented infected embolic foci of septic infiltrates or represented a concentration of leukocytes, which is true in cases of leukemia and in some cases of bacterial endocarditis.2 However, the white center actually represents a fibrin-platelet thrombus.3 It typically results from the rupture of retinal capillaries and the extrusion of whole blood.
Under normal circumstances, retinal capillary endothelium is impermeable to the transmission of whole blood, but with any anoxic event or sudden elevation in venous pressure, or both, the capillaries rupture and whole blood is extruded.4
Subsequent reparation leads to platelet adhesion and coagulation cascade at the site of the damaged endothelium and results in the formation of a fibrin-platelet thrombus.3 Morphologically, this thrombus appears as a pale white lesion in the center of the hemorrhage.
A diverse list of conditions can lead to retinal capillary rupture and result in white-centered hemorrhages (see box). They can be subclassified according to underlying mechanism, such as thrombocytopenia, elevated venous pressure (Valsalva phenomenon), ischemia, or capillary fragility.2,4
Thrombocytopenia is often associated with subacute bacterial endocarditis and acute leukemia, in which the body cannot produce ample platelets and leads to internal and external bleeding.5
Elevated venous pressure is seen with mothers who have undergone traumatic deliveries, neonatal birth trauma, battered children/shaken baby syndrome, intracranial hemorrhage from arteriovenous malformation, or prolonged intubation during anesthesia.6
Ischemic events can include anemia, anoxia, or carbon monoxide poisoning.4
Capillary fragility, as is the case with our patient, is often associated with diabetic retinopathy, hypertensive retinopathy, oral contraceptives, or idiopathic cases.6
Incidence with diabetes
White-centered hemorrhages are relatively common to see in cases associated with diabetes.
In one particular study, 215 diabetic patients (430 eyes) with early proliferative retinopathy, moderate to severe non-proliferative retinopathy, and/or diabetic macular edema in each eye were evaluated for the presence of such white-centered hemorrhages.7
The study found that 15.6 percent of these eyes demonstrated at least one white-centered hemorrhage, and 4.9 percent of the eyes showed five or more white-centered hemorrhages. In addition, there was no statistically significant difference in incidence of macular capillary injury between those with and without concurrent white-centered hemorrhages.7
1. Erneston AG, Bradford MB. Clinical laboratory analysis of white-centered hemorrhages. J Am Optom Assoc. 1986 Aug;57(8):617-20.
2. Fred HL. Little black bags, opthalmoscopy, and the Roth spot. Tex Heart Inst J. 2013;40(2):115-6.
3. Ling R, James B. White-centred retinal haemorrhages (Roth spots). Postgrad Med. J. 1998 Oct;74(876):581-2.
4. Duane TD, Osher RH, Green WR. White centered hemorrhages: Their significance. Ophthalmology. 1980;87(1):66-9.
5. Cleveland Clinic. Thrombocytopenia. Available at: https://my.clevelandclinic.org/health/diseases/14430-thrombocytopenia. Accessed 10/30/19.
6. Törnqvist G, Mártenson PA. Retinal white-centered hemorrhages in infectious mononucelosis. Acta Ophthalmol Scand. 1997 Feb;75(1):99-100.
7. Catalano RA, Tanenbaum HL, Majerovics A, et al. White centered retinal hemorrhages in diabetic retinopathy. Ophthalmology. 1987 Apr;94(4):388-92.
8. Dell’Arti L, Barteselli G, Pinna V, et al. Sudden occurrence of Roth spots and retinal hemorrhages following endoscopic adhesiolysis: an SD-OCT evaluation. Eur J Opthalmol. 2015 Dec 1;26(1):e11-3.
9. Javaheri M, Bertoni B, Eliott D. White-centered retinal hemorrhages. Consultant 360. 2012; 52(8). Available at: https://www.consultant360.com/article/white-centered-retinal-hemorrhages. Accessed 10/30/19.