Eyes Wide Shut: A Cohort Study Questioning the Role of Fundoscopy in Infective Endocarditis Diagnosis.

In this retrospective/prospective study, we assessed the role of fundoscopy in 711 episodes with suspected infective endocarditis (IE); 238 (33%) had IE. Ocular embolic events (retinal emboli or chorioretinitis/endophthalmitis) and Roth spots were found in 37 (5%) and 34 (5%) episodes, respectively, but had no impact on IE diagnosis.

Highlights of ophthalmological manifestations in newly diagnosed acute leukemia: a correlation with hematological parameters.

Acute leukemia is a hematological malignancy affecting different organ systems including the eye and orbit through direct infiltration of tissues or secondary to hematological abnormalities. Ophthalmological manifestations in acute leukemia are variable ranging from asymptomatic presentation to serious manifestations that can alter the disease course and treatment. The purpose of this study is to detect the incidence of different ophthalmological manifestations in newly diagnosed acute leukemia patients and to assess the relationship between ocular findings and hematological characteristics and the sequel of these neoplasms. A cross-sectional study with analytical components was conducted on 222 newly diagnosed acute myeloid and acute lymphoblastic leukemia patients who presented at Oncology Center Mansoura University (OCMU) between January 2022 and February 2023. All patients underwent a complete ophthalmic evaluation at Mansoura Ophthalmology Center (MOC). The mean age was 43.45 ± 17.35 years (range, 17-85), and M/F was 137 (61.7%)/85 (38.3%). One-hundred and forty-four (64.9%) had acute myeloid leukemia (AML), and 78 (35.1%) had acute lymphoblastic leukemia (ALL). Ophthalmic manifestations were detected in 96 patients (43.2%). Among them, 4 (1.8%) had poor visual acuity. Retinal hemorrhage (19.8%) and Roth spots (17.1%) were the most common ocular manifestations. Other ophthalmological manifestations observed were orbital involvement (3.2%), ocular motility issues (1.4%), subconjunctival hemorrhage (5.9%), conjunctival chemosis (0.9%),lid swelling (4.1%), lid ecchymosis (3.2%), lagophthalmos (0.5%), lid ptosis (1.8%), retinal venous congestion & tortuosity (4.1%), preretinal hemorrhage (3.2%), vitreous hemorrhage (3.2%), macular affection (2.3%), retinal infiltration (1.8%), exudative retinal detachment (ERD) (1.8%), cotton-wool spots (0.9%), retinal vein occlusion (0.5%), papilledema (2.8%), optic disc infiltration (1.8%), disc pallor (1.8%).AML patients were significantly associated with a higher frequency of ocular affection, retinal hemorrhages, and Roth spots (P 0.028, 0.003, and 0.046, respectively) compared to ALL patients. Retinal hemorrhage was statistically significantly associated with anemia (P 0.021). Ophthalmological manifestations of acute leukemia are heterogeneous; they can be detected at initial presentations or relapse. Some manifestations are asymptomatic, others can affect visual acuity or even alter the disease course. Cooperation between ophthalmologists and haemato-oncologists is crucial for recognizing ocular involvement and disease management.

Bilateral vision loss at high altitude: A diagnostic dilemma.

A young male patient of 22 years inducted at 11,000 feet altitude presented with a sudden onset bilateral diminution of vision associated with easy fatiguability and generalised weakness. Fundus examination revealed preretinal haemorrhages and Roth spots both eyes, owing to which differential diagnosis of high altitude retinopathy (HAR) and haematological disorders was considered. On systemic examination, he had pallor with massive splenomegaly. Haematological investigation revealed high total leucocyte count (TLC) 2.96 lac (normal 4000-11,000/uL) with peripheral blood smear showing increase in basophils, neutrophil precursors, myelocyte bulge, anaemia with no blasts suggestive of chronic myeloid leukaemia-chronic phase. Hence, a diagnosis of chronic myeloid leukaemia (chronic phase) with no features of tumour lysis syndrome was made. Patient was started on Tab hydroxyurea 50 mg twice a daily and managed by haemato-oncologist and required no further active ophthalmological intervention.

Value of diagnosing immunological phenomena in patients with suspected endocarditis.

PURPOSE: Immunological phenomena are a minor criteria in the modified Duke Criteria for endocarditis. Given the changes in epidemiology and diagnostics, the added value of determining these phenomena in today's patients with suspected endocarditis is unknown. METHODS: In a retrospective cohort study of all patients with suspected endocarditis admitted to our hospital and discussed in our endocarditis team, we determined the proportion of patients classified as definite endocarditis because of either positive IgM rheumatoid factor (IgM RF), haematuria, or Roth's spots on ophthalmology consultation. We also determined diagnostic accuracy of each of these immunological phenomena separately and combined. RESULTS: Of 285 patients included, 138 (48%) had definite endocarditis and at least one immunological test was performed in 222 patients (78%). Elevated IgM RF was found in 22 of 126 patients tested (17%), haematuria in 78 of 196 tested (40%) and Roth's spots in six of 120 tested (5%). Eighteen of 138 patients with definite IE (13%) were classified as such because of a positive IgM RF, haematuria or Roth's spots. Haematuria had the highest sensitivity: 50.5% (95% CI 40.4-60.6) and Roth's spots the highest specificity: 98.3% (95% CI 90.8-99.9). The diagnostic accuracy results were robust in a sensitivity analysis aimed at avoiding incorporation bias. CONCLUSION: Among patients with a clinical suspicion of endocarditis, recommended systematic testing for immunological phenomena helped classify more patients as definite IE and is useful to confirm the diagnosis of endocarditis.

[Infective endocarditis in a patient with vision disorders]. / Infekcyjne zapalenie wsierdzia u chorej z zaburzeniami widzenia.

Roth spots are petechiae of the retina with a white or pale center that corresponds to a bundle of cotton wool or a multinuclear leukocyte aggregate. Often considered a sign of bacterial endocarditis, they are an unspecific symptom, usually more commonly seen in patients with hematopoietic system diseases. A 56-year-old patient reported to the hospital due to sudden visual impairment. The fundoscopy revealed Roth spots in both eyes that aroused the suspicion of infective endocarditis. After confirming the condition at the Department of Cardiology and the implementation of the treatment, there was a significant improvement in visual acuity, including the resolution of retinal changes. The presented case presents an accurate, still rare ophthalmic diagnosis of infective endocarditis.

Atypical Case of MOG Antibody-Associated Optic Neuritis with Roth Spots.

PURPOSE: To report an atypical case of MOG antibody-associated optic neuritis with Roth spots and widespread retinal hemorrhages. CASE REPORT: A 49-year-old woman complained of 1 week history painful visual loss in the left eye. Funduscopy exam showed a severe optic disc edema associated with multiple peripapillar hemorrhages, peripheral retinal hemorrhages and Roth spots in the left eye. Orbit MRI revealed an hyperintensity in the left optic nerve, enhanced with gadolinium. The serum Myelin Oligodendrocyte (MOG) antibodies was found positive. Early intravenous high dose of steroids rapidly improved visual acuity and fundus abnormalities rapidly resolved. CONCLUSION: Retinal hemorrhages can also be detected in case of optic disc edema associated with an optic neuritis, as seen in MOGAD.

An Atypical Case of Exogeneous Endophthalmitis after Intravitreal Injection Presenting with Roth Spots.

PURPOSE: To report an atypical case of exogeneous endophthalmitis presenting with Roth spots. CASE: A 67-year-old man presented with decreased vision, mild pain, and discomfort in his left eye 12 days after an intravitreal aflibercept injection. Best-corrected visual acuity was 20/200, and there were +3 anterior chamber cells. On fundus examination, multiple intraretinal hemorrhages with a central white core resembling a Roth spot were observed. Intravitreal antibiotic injections were performed, and a vitreous sample was taken. Although post-intravitreal injection history was available, full systemic screening was planned to rule out endogenous endophthalmitis because of the presence of these Roth spots. Vitrectomy was performed and methicillin-sensitive coagulase-negative Staphylococcus was detected on culture. CONCLUSION: Although the presence of Roth spots is an unexpected finding in post-injection endophthalmitis, it was nevertheless demonstrated in our case. For this reason, it should be kept in mind that Roth spots can be encountered in bacterial endophthalmitis.

Bilateral Serous Detachments with Roth Spots after COVID-19 Vaccination: A Case Report.

With the rise of novel types of vaccines during the pandemic, new side effects are encountered. The aim of this paper is to describe an atypical case of bilateral serous detachments with Roth spots after COVID-19 vaccination using an mRNA vaccine. A healthy, 38-year-old male presented with a central scotoma and metamorphopsia in his left eye, 4 days after his second COVID-19 booster shot. Bilateral serous detachments were seen, with one area showing Roth spots. Patient's symptoms resolved spontaneously without any treatment. Although serous detachment after COVID-19 vaccination has been described in the context of other diseases, such as Vogt-Koyanagi-Harada disease, central serous chorioretinopathy, and posterior scleritis, this is the first report of serous detachments with Roth spots as an isolated entity.

White-centered retinal hemorrhage revealing acute leukemia: A case report.

Retinal manifestations have been described as an inaugural manifestation of acute leukemia. Retinal hemorrhage, and in particular white-centered hemorrhages are among the most frequently observed signs. We report here the case of a 34-year-old Caucasian man with no medical history who presented to our emergency department with a decrease in visual acuity associated with asthenia. Ophthalmological examination revealed bilateral white-centered hemorrhages. The etiological assessment confirmed the diagnosis of acute myeloid leukemia. Whenever Roth spots are found in fundus examination, a complete ophthalmological examination along with a wide etiological investigation must be conducted.

Ophthalmic Manifestations as First Presenting Sign of Evans Syndrome.

Purpose: This work reports a case of Evans syndrome first presenting with ophthalmic signs. Methods: A 27-year-old previously healthy man presented with headaches and bilateral blurred vision for 2 weeks. The visual acuity was 20/30-1 and 20/60-2 in the right eye and left eye, respectively. A fundus examination revealed Roth spots, diffuse multilayer retinal hemorrhages in the macula and periphery, and tortuous vessels in both eyes. Optical coherence tomography showed a disrupted foveal contour from intraretinal fluid and hemorrhage in both eyes. Fluorescein angiography demonstrated dilated and tortuous vessels with scattered blocking defects from hemorrhages. Results: A workup revealed warm hemolytic anemia with severe thrombocytopenia consistent with the diagnosis of Evans syndrome. Conclusions: Evans syndrome is a rare blood dyscrasia that can first present as subacute vision loss and should be added to the differential of diffuse bilateral retinal hemorrhages spanning a multitude of retinal layers.

Bilateral vision loss as initial presentation of chronic myeloid leukemia in a young adult: A case report and review of the literature.

Purpose: To report a case of bilateral vision loss as the primary presenting symptom of chronic myeloid leukemia in a young adult. Observations: The 28-year-old male patient presented to clinic with visual acuity of 20/200 in both eyes after several months of episodic bilateral vision loss. Intraretinal and pre-retinal hemorrhages were appreciated, as well as Roth spots and peripheral neovascularization. Initial lab findings were consistent with a diagnosis of acute myeloid leukemia, later, upon bone marrow examination, the diagnosis was edited to chronic myeloid leukemia. Dasatinib therapy resulted in a complete hematologic resolution after six weeks. After intravitreal injections of bevacizumab in both eyes, visual acuity improved to 20/25 in the right eye and 20/20 in the left eye. Conclusion and importance: After review, this is one of only a few reported cases of bilateral blurry vision as the primary presenting symptom of chronic myeloid leukemia in a young adult. Because visual disturbances occur more frequently in acute myeloid leukemia, and lab results may be inconclusive, careful consideration should be given to differentiate myelogenous leukemias, as the acute and chronic subtypes may present similarly.

Vaping-Related Clotting Phenomena Presenting As Central Retinal Vein Occlusion.

Central retinal vein occlusion (CRVO) typically manifests as unilateral vision loss from thrombosis and occlusion of the central retinal vein in patients with thrombophilic risk factors. Here we report a case of a 23-year-old male with three weeks of intermittent left-sided eye pressure and vision loss, who was found to have decreased visual acuity, retinal hemorrhages, and an impending CRVO in his left eye. Upon further evaluation, infectious disease and autoimmune labs were normal, but he had mildly increased right heart pressures and hypercoagulable changes in the right middle cerebral artery. He denied any personal or family history of clotting disorders but noted a four-year history of vaping. He was started on anticoagulation and discharged. Outpatient genetic testing for Factor V Leiden, protein C, protein S, and prothrombin G20210 was normal. His visual acuity returned to normal in the left eye and the retinal hemorrhages resolved. After the exclusion of organic causes, significant vaping history was considered the likely etiology of his hypercoagulable state and resultant CRVO. Vaping-related clotting phenomena may explain the etiology of an otherwise unexplained CRVO, but further investigation of the long-term health consequences of electronic cigarette use is still needed.

An Uncharacteristic Presentation of Evans Syndrome Following Treatment With Dupilumab.

Evans syndrome is a rare autoimmune disorder where patients develop autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and less commonly immune neutropenia. Patients typically present with fatigue, pallor, jaundice, petechiae, or epistaxis. A 27-year-old man with a history of atopic dermatitis for which he recently began treatment with dupilumab presented to the emergency department with a headache and blurry vision. Multiple Roth spots were seen on fundoscopic examination. Laboratory studies were consistent with warm AIHA, confirmed by a positive direct antiglobulin test (DAT), and severe thrombocytopenia. He was diagnosed with Evans syndrome. He was treated with corticosteroids, rituximab, and intravenous immunoglobulin (IVIG). His recovery was prolonged with the slow improvement of anemia and thrombocytopenia. This is an atypical presentation of Evans syndrome with isolated symptoms of new-onset blurry vision and headache along with the finding of Roth spots. Another interesting feature in the case is the recent use of dupilumab. Dupilumab is a monoclonal antibody that inhibits the T-helper cells type 2 (Th2) signaling pathway by blocking interleukin (IL)-4 and IL-13 binding. This alteration in the immune response could have a role in the development of Evans syndrome.

Covid-19-Associated Retinopathy: A Case Report.

A 53-year-old man presented with acute loss of vision, negative scotoma and dyschromatopsia in his left eye. He reported contact with people with severe respiratory syndrome - coronavirus-2 (SARS-CoV-2) 8 days prior symptoms. Funduscopic examination revealed several retinal hemorrhages. Spectral-domain optical coherence tomography showed lesions consistent with acute macular neuroretinopathy and paracentral acute middle maculopathy. Quickly after his presentation, SARSCov-2 was confirmed by chest computed tomography-scan and RT-PCR in this patient. Thrombotic complications associated with Covid-19 infection have high incidence and may involve the retina. We described a case of retinal involvement associated with Covid-19 infection. PRÉCIS: Funduscopic examination revealed retinal hemorrhages in a man with loss of vision. Optical coherence tomography showed an acute macular neuroretinopathy and paracentral acute middle maculopathy. Coronavirus disease was confirmed by chest computed tomography-scan and RT-PCR.

[Shaken-baby syndrome and unilateral retinal hemorrhage?] / Shaken-Baby-Syndrom bei unilateraler retinaler Hämorrhagie?

Unilateral retinal hemorrhage in infants can be caused by vitamin K deficiency. The case described here with fatal outcome presents the medical history of a 2-month-old infant with vitamin K deficiency bleeding caused by the refusal of vitamin K prophylaxis by the parents. Ocular signs were unilateral intraretinal hemorrhage with Roth spots and preretinal hemorrhage over the complete back of the eye. The case demonstrates the importance of vitamin K prophylaxis for newborns.

Roth Spots in Ocular Toxoplasmosis.

PURPOSE: To report a case with unilateral preexisting ocular toxoplasmosis (OT) and newly occurred active retinochoroidal inflammation associated with white-centered retinal hemorrhages (Roth spots) in the healthy eye. DESIGN: Case report. METHODS: A 20 year-old man presented with a decrease of visual acuity in his right eye associated with 2+ cells in the anterior chamber. Ophthalmoscopy revealed an active retinochoroidal lesion on the upper nasal border of the optic disc associated with local hemorrhage and vitritis. The posterior pole presented white-centered flame-shaped retinal hemorrhages. RESULTS: Toxoplasmosis serology showed an IgG titer >300IU/ml and a negative IgM titer. A complete blood count revealed no abnormalities; other serologies were negative. After 2 weeks of treatment with sulfadiazine, pyrimethamine, folinic acid and prednisone, although the peripapillary lesion was still active, the Roth spots disappeared. CONCLUSION: OT may be one differential diagnosis of patients suffering Roth spots in association with retinochoroidal inflammation.