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| CLINICAL IMAGE |
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| Year : 2023 | Volume
: 16
| Issue : 1 | Page : 192-194 |
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Roth spots revealing idiopathic aplastic anemia
Amine Zahaf1, Houda Lajmi1, Malek Belhaj2, Camelia Chaftar2, Besma Ben Achour1, Wassim Hmaied1
1 Department of Ophthalmology, Internal Security Forces Hospital, La Marsa; Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
2 Department of Ophthalmology, Internal Security Forces Hospital, La Marsa, Tunisia
| Date of Submission | 02-Feb-2022 |
| Date of Decision | 26-Aug-2022 |
| Date of Acceptance | 02-Dec-2022 |
| Date of Web Publication | 21-Feb-2023 |
Correspondence Address:
Amine Zahaf
Department of Ophthalmology, Internal Security Forces Hospital, La Marsa, Tunis
Tunisia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.ojo_37_22
 Abstract | | |
Keywords: Aplastic anemia, hyaloidotomy, neodymium-doped yttrium aluminum garnet laser, Roth spots, subhyaloid hemorrhage
How to cite this article:
Zahaf A, Lajmi H, Belhaj M, Chaftar C, Achour BB, Hmaied W. Roth spots revealing idiopathic aplastic anemia. Oman J Ophthalmol 2023;16:192-4 |
Aplastic anemia (AA) is a rare, idiopathic, or immune-mediated hematopoietic disorder associated with a high risk of morbidity and mortality. Ocular manifestations are common in AA. Nevertheless, Roth spots have been rarely reported.
We report a case of a 19-year-old male presented with an acute, painless, and blurred vision for the past 2 days. He reported having an occasional gingival bleeding for the past 2 weeks. There was no other significant medical history to be taken into account. On ocular examination, the best-corrected visual acuity was 8/10 in the right eye (OD) and 4/10 in the left eye (OS). The slit-lamp examination and tonometry were normal in both eyes. Dilated fundus evaluation revealed multiple scattered, white-centered retinal hemorrhages in both eyes and a large sedimented subhyaloid hemorrhage with a characteristic fluid level involving the lower half of the posterior pole of the OS [Figure 1]. Physical examination showed mucocutaneous pallor. The complete blood count showed pancytopenia with a hemoglobin concentration of 5.1g/dl, white blood cells of 890/mm3, and platelet count of 11000/ml. Consequently, the patient was hospitalized in the hematologic department and had been transfused by red blood cells and platelets. A bone marrow biopsy was performed diagnosing idiopathic AA. An ophthalmological examination was performed 7 days later. Persistence of the premacular hemorrhage in the OS was noted and could present a significant risk of toxic damage of the retina. Accordingly, a hyaloidotomy by neodymium-doped yttrium aluminum garnet (Nd: Yag) laser with two shots at 2.2 mJ was carried out. Consequently, the blood slowly started to spread into the vitreous body space [Figure 2]. Visual acuity in the OS improved rapidly within 2 days and achieved 10/10. Ten days later, our patient reported an acute visual loss in the OD. The best-corrected visual acuity was hand motion in the OD, and fundus evaluation revealed a very large subhyaloid hemorrhage. Therefore, a hyaloidotomy by Nd:Yag laser with three shots at 3 mJ was performed [Figure 3]. Two days later, a fundus examination revealed the beginning of clearance of the blood in front of the fovea [Figure 4]. Seven days later, visual acuity OD achieved 3/10. Unfortunately, our patient presented a large hematoma on the floor of the mouth. He was transferred to intensive care and passed away a few days later. | Figure 1: Fundus photograph showing premacular subhyaloid hemorrhage (blue arrow) and Roth spots (yellow arrow). (a) Right eye. (b) Left eye
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 | Figure 2: Fundus photograph of the left eye after Nd:YAG laser hyaloidotomy. Nd:YAG: Neodymium-doped yttrium aluminum garnet
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 | Figure 3: Fundus photograph immediately after treatment by Nd:YAG laser hyaloidotomy of a very large subhyaloid hemorrhage of the right eye showing the blood slowly started to spread into the vitreous body space. Nd:YAG: Neodymium-doped yttrium aluminum garnet
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 | Figure 4: Fundus photograph 2 days after Nd: YAG laser hyaloidotomy of the right eye showing the beginning of clearance of the blood in front of the fovea. Nd:YAG: Neodymium-doped yttrium aluminum garnet
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AA is a life-threatening hematologic disease resulting from the autoimmune destruction of hematopoietic stem cells. The first incidence peak of AA is in young patients between 15 and 25 years of age, and the second peak is in older adult patients of 60 years of age.[1] In patients with suspected AA, a rapid and accurate diagnosis and concomitant supportive care are critical.
The most reported ocular manifestations of AA are retinal hemorrhages, vitreous or subhyaloid hemorrhage, and peripheral retinal vasculopathy.[1]
White-centered retinal hemorrhages or Roth spots are a morphological manifestation of the retinal capillary rupture and the ensuing reparative process. They are previously thought to be pathognomonic for subacute bacterial endocarditis. However, many reported numbers of other conditions can be associated with Roth spots as hypertensive retinopathy, diabetic retinopathy, anoxia, anemia/thrombocytopenia, intracranial hemorrhage, leukemia, prolonged intubation, complicated delivery, and neonatal birth trauma.[2]
The management of patients with Roth spots is based on the identification of the causative etiology to prevent systemic and ocular complications that may occur due to the underlying disease.
Small preretinal hemorrhages can resolve spontaneously, but large amounts of blood may cause macular toxic damage due to a prolonged contact with hemoglobin and iron.
Various techniques have been described to treat premacular subhyaloid hemorrhage. These include observation, Nd: YAG laser hyaloidotomy, vitreal injection of recombinant tissue plasminogen activator with gas, and pars plana vitrectomy.[3],[4]
Drainage of subhyaloid hemorrhage using Nd:YAG laser assisted was described in the 1980s.[5] Advantages of Nd: YAG laser treatment are rapid improving vision by rapid resolution of subhyaloid hemorrhage and preventing the need for vitreoretinal surgery.
A careful positioning of hyaloidotomy and the gradually increasing energy level might be of significant importance in performing Nd: YAG laser hyaloidotomy.[3]
We insist on the fact that Roth spots may occur in a several life-threatening pathological conditions; thus, serious etiological investigations are required. The management of premacular subhyaloid hemorrhage by Nd:YAG laser offers an immediate improvement of vision.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Mansour AM, Lee JW, Yahng SA, Kim KS, Shahin M, Hamerschlak N, et al. Ocular manifestations of idiopathic aplastic anemia: Retrospective study and literature review. Clin Ophthalmol 2014;8:777-87.  |
| 2. | Falcone PM. Vitreomacular traction syndrome confused with pseudophakic cystoid macular edema. Ophthalmic Surg Lasers 1996;27:392-4. |
| 3. | Khadka D, Bhandari S, Bajimaya S, Thapa R, Paudyal G, Pradhan E. Nd: YAG laser hyaloidotomy in the management of Premacular Subhyaloid Hemorrhage. BMC Ophthalmol 2016;16:41. |
| 4. | Brent BD, Gonce M, Diamond JG. Pars plana vitrectomy for complications of retinal arterial macroaneurysms – A case series. Ophthalmic Surg 1993;24:534-6. |
| 5. | Faulborn J. Behandlung einer diabetschen praemaculaeren Blutung mit dem Q-switched Neodym: YAG laser. Spektrum Augenheilkd 1988;2:33-5. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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