The study also found that there was no significantly higher prevalence of systemic or hematologic disorders in patients with diabetic retinopathy and white-centered hemorrhages.7
More specifically, there was no statistically significant difference between patients with and without white-centered hemorrhages in regard to the presence of increased systolic or diastolic pressure, hemoglobin levels, leukocyte counts, platelet numbers, increased serum creatinine values, or abnormal coagulation profiles.7
Even though our patient’s Roth spot presented other retinal findings consistent with diabetic retinopathy, it is still imperative to rule out all other possible etiologies for the isolated white-centered hemorrhage before concluding capillary fragility as a result of diabetes mellitus as the most likely culprit.
Owing to the plethora of possible etiologies for the white-centered hemorrhage, it is imperative to match symptomatology, ocular signs, laboratory tests, and confirmatory results in order to reach a proper underlying diagnosis.
For example, symptoms including fever, weakness, ecchymosis, hematuria, and/or infections along with ocular signs of white-centered hemorrhages, tortuous engorged vessels, vitreous hemorrhage, retinal detachment, retinal edema, and cotton wool spots, would indicate necessary lab testing with CBC with white blood cell (WBC) differential to rule out acute leukemia. A normal or decreased WBC count and WBC differential showing predominantly immature cells would definitively confirm such diagnosis.1
Common diabetes symptoms include weakness, weight loss, polyphagia, polydipsia, and/or polyuria. Ocular signs include diabetic retinopathy, fluctuations in refractive error, diplopia, optic atrophy, optic neuritis, and white-centered hemorrhages. Lab tests imperative to perform include fasting blood sugar and glucose tolerance test.1
Given our patient’s lab results of elevated blood glucose, personal medical history, and lack of acute infectious symptoms, it was appropriate to assume the underlying etiology was diabetes mellitus for the isolated white-centered hemorrhage.
The primary-care physician was notified of this retinal finding to consider the possibility of re-initiating medication for his diabetes, which is what ultimately happened.
Management for Roth spots is influenced by their underlying cause. The optometrist should refer patients to the appropriate physician in order to treat the underlying disease process.
However, there is no specific treatment for the white-centered hemorrhage itself; it usually self resolves within six weeks.8 Patients who present with these non-specific lesions require a prompt comprehensive evaluation to determine the cause. Once it is determined, treatment for the underlying etiology is the priority.9
Our patient’s isolated presentation of a Roth spot showcases the strong link between ocular and systemic health. Although there is no specific treatment for the lesion itself, it is of paramount importance that the clinician promptly performs a thorough review of systems and orders the appropriate lab testing to determine the lesion’s underlying etiology and initiate treatment for that condition.
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.