ROTH SPOTS: PATHOPHYSIOLOGY, FUNDUS AND IMPORTANCE - ANATOMY AND PHYSIOLOGY - 2025

It is known as Roth 's spots small bleeding points located in the retina that are characterized by a white center. They are visible on the fundus exam, also called ophthalmoscopy, which the doctor performs during the physical exam.

When they were described in 1872 they were thought to be an exclusive sign of bacterial endocarditis. Roth spots are currently known to be caused by the rupture of the blood vessels in the retina. This rupture can be caused by a large number of systemic diseases.

Cottony spots on the retina. By http://www.nei.nih.gov/photo/eyedis/index.asp, Public Domain, commons.wikimedia.org

If the cause of these hemorrhages is infective endocarditis, other signs can be seen such as Janeway's lesions, which are small inflammatory patches of the skin, as well as Osler's nodules, which appear as very subcutaneous cysts. painful that are located on the soles and palms.

When finding Roth spots in the clinical evaluation of a patient, the physician must investigate the underlying cause through history, physical examination, and laboratory tests.

Pathophysiology

Retinal hemorrhages with a white center, called Roth spots, have been studied for years without a good understanding of their formation process.

During the 19th century, after their discovery, they were thought to be a specific and exclusive sign of bacterial infection of the inner layer of the heart or endocardium. For this reason they were described as small bacterial thrombi that formed abscesses in the retina and caused hemorrhage.

It is currently known that the white center of Roth spots contains very few cells, so it is not likely to be an abscess, as these contain abundant amounts of white blood cells.

On the contrary, this white element corresponds to an area of ​​fibrin with a platelet block, which is formed by damage to the delicate blood vessels that nourish the retina.

Retinal capillaries are sensitive to changes in blood pressure, which can cause injury and bleeding. Therefore, patients with high blood pressure may present this sign.

In some pathologies, the presence of Roth spots is explained because the body forms immune deposits that end up accumulating in areas of thin blood vessels, such as the retina, the renal glomeruli, and the fingers and toes. This is the case with endocarditis.

Eye fundus

In the comprehensive physical examination, the doctor must perform the ocular evaluation, including inspection and ophthalmoscopy or fundus.

This assessment seeks to evaluate the inner part of the eye, which includes the retina, through the diaphragm of the pupil.

To do this, a manual instrument called an ophthalmoscope is used, which has a light and a mirror system that allows the doctor to see the cavity of the eyeball. You also choose to dilate the pupil with special drops for this purpose.

Ophthalmoscope (left) and otoscope (right). By James Heilman, MD - Own work, Public Domain, commons.wikimedia.org

This is an evaluation that requires experience, since it is based on the visualization of the structures by the doctor, who must know the normal appearance to identify any pathological changes.

Ophthalmoscopy, or fundus, is a basic exam for physical evaluation. Every doctor must know how to perform it since it provides important and unique data on the patient's condition, as well as vascular damage caused by the disease he suffers, severity and even prognosis.

Doctor performing ophthalmoscopy. By NIH - http://www.nei.nih.gov/rop/photos.asp (follow page link to relevant subject; page may have changed since upload), Public Domain, commons.wikimedia.org

In addition to this, very advanced equipment is not needed to perform it and it can establish correct diagnoses and approaches.

Findings in the retina

The retina is a tissue that is found covering the entire interior part of the eye. It has a network of blood vessels whose integrity must be evaluated in detail during the fundus, since they are small capillaries that are relatively easily injured.

Parts of the human eye. By Human eye cross section detached retina.svg: Erin Silversmith from an original by en: User: Delta Gderivative work: RexxS, Aibdescalzo (talk) - Human eye cross section detached retina.svg, CC BY-SA 3.0, commons.wikimedia. org

Bleeding is a frequent finding in patients diagnosed with high blood pressure, diabetes and anemia, among other diseases.

However, other hemorrhagic signs, such as Roth spots, can be seen without the patient reporting any symptoms.

Importance of Roth spots

Roth spots were discovered in 1872 by the Swiss pathologist Moritz Roth, who described them as red spots on the retina with a white center that were located near the optic center. However, it was the German physician Moritz Litten who studied them in depth and introduced the eponymous into the medical literature.

Litten discovered that this finding was found in patients with infectious heart disease, especially endocarditis caused by bacteria. This is why it was considered to be a sign that ensured this condition in the patient who presented them.

Cottony spots in diabetes. By BruceBlaus. When using this image in external sources it can be cited as: Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI: 10.15347 / wjm / 2014.010. ISSN 2002-4436. - Own work, CC BY 3.0, commons.wikimedia.org

Later it was possible to establish the presence of Roth's spots in different systemic diseases in addition to bacterial endocarditis, including various types of anemia, toxoplasmosis, diabetes mellitus or HIV. Therefore, it is a finding indicative of severe or advanced disease.

Diagnostic approach in the patient with Roth's spots

When Roth spots are evident in the fundus, it should be investigated in depth in order to establish a proper diagnosis and treatment.

Patients who have dramatic symptoms such as fever and chills, night sweats, and malaise may develop bacterial endocarditis.

In these cases, Roth's spots will be accompanied by other signs on the skin and mucous membranes such as small hemorrhages on the palate, raised spots on the skin (known as Janeway lesions), and subcutaneous painful nodules on the balls and soles of the feet. (called Osler's nodules).

In asymptomatic patients with the sign, some type of chronic anemia may be suspected. Vitamin B12 deficiency anemia, called pernicious anemia, can be suspected from the finding of Roth's spots.

The definitive diagnosis is made through blood tests that indicate decreased hemoglobin and vitamin B12 values. In these cases, the spots disappear when the treatment is administered and the values ​​return to normal.

In the case of chronic diseases such as high blood pressure or diabetes, the finding of Roth spots is indicative of inadequate control of the disease. These cases can lead to retinal bleeding and clots that cause vision loss.

References

1. Ruddy, S. M; Bergstrom, R; Tivakaran, VS (2019). Roth Spots. StatPearls. Treasure Island (FL). Taken from: ncbi.nlm.nih.gov
2. Fred, HL (2013). Little black bags, ophthalmoscopy, and the Roth spot. Texas Heart Institute journal. Taken from: ncbi.nlm.nih.gov
3. Ling, R., & James, B. (1998). White-centered retinal haemorrhages (Roth spots). Postgraduate medical journal. Taken from: ncbi.nlm.nih.gov
4. Senior, J. M; Gándara-Ricardo, JA (2015). Infectious endocarditis. Taken from: scielo.org.co
5. Holland, T. L; Baddour, L. M; Bayer, A. S; Hoen, B; Miro, J. M; Fowler, V. G (2016). Infective endocarditis. Nature reviews. Disease primers. Taken from: ncbi.nlm.nih.gov
6. Macauley, M; Nag, S. (2011). Roth spots in pernicious anaemia. BMJ case reports. Taken from: ncbi.nlm.nih.gov