Download Leukemic Retinopathy - University of Louisville Ophthalmology

Grand Rounds Conference
Eric Downing MD
University of Louisville
Department of Ophthalmology and Visual Sciences
9/4/2015
Subjective
CC/HPI: 55M with complaint of floater and
blurry vision just temporally OD x 5 days.
POH: none
PMH: liver cirrhosis and ascites 2/2 EtOH abuse,
anemia and thrombocytopenia, DM2, HTN,
morbid obesity
Eye Meds: none
Meds: Insulin, Metoprolol, Lisinopril, Lasix,
Albumin
Objective
VA:
Pupils:
IOP:
EOM:
CVF:
OD
20/253→2
14
full
full
OS
20/20
3→2, no rAPD
12
full
full
Objective
SLE:
E/L/L:
C/S:
K:
AC:
I/L:
Vit:
DFE:
WNL OU
White, quiet OU
Clear OU
D&Q OU
1+NS OU
no vitritis
Clinical photos
Differential Diagnosis
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Subacute bacterial endocarditis
Anemia
Leukemias
Diabetes
HTN
Sepsis
Labs
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WBC: 17.1
Hgb/Hct: 6.7/20.4
Plt: 29
Blood culture: negative
Blood smear: many immature granulocytes and
blast cells
TEE with no vegetations
Assessment
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55M with multiple retinal hemorrhages and Roth
spots OU.
Elevated WBC with elevated blast ratio
Anemia/thrombocytopenia
Dx: Acute Myelogenous Leukemia with
Leukemic retinopathy
Plan
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Chemo not initiated due to comorbidities
Palliative 5 day course of Decitabine initiated
Roth Spot
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Originally described as
Retinitis Septica by Moritz
Roth in 1872
In 1878 Litten termed
them the Roth spot
Now the term is used to
describe any whitecentered hemorrhage
Histopathology
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Retinal capillary rupture
Extrusion of whole blood
Platelet adhesion and
activation
Coagulation cascade
Platelet-fibrin thrombus
Subacute Bacterial Endocarditis
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History: fever, night sweats,
weight loss, dental work
Fever (90%), heart murmur
(85%), petechiae, splinter
hemorrhages, Osler’s nodes
Polymorphous or
mononuclear cells with a
surrounding hemorrhage
Roth spots only observed in
5% of these patients
Litten’s sign: CWSs associated
with SBE
Leukemias
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Ocular findings in about 40%
Positive correlation between
levels of anemia and/or
thrombocytopenia
Exam
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Hemorrhages involving any/all
layers of retina
Perivascular sheathing
Pale-swelling of the optic nerve
Vascular tortuosity possibly
related to hyperviscosity
CWS are poor prognostic factor
Anemia
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Central fibrin collection
with heme
Retinopathy observed in
~28% of pts, especially
those with Hgb <8 and
plt <50
75% also have
conjunctival pallor
Prognostic Importance of
Retinopathy in Acute Leukemia
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Prospective study of 54 patients with ALL or
AML
35% had retinopathy at diagnosis
In general, those with retinopathy fared worse
Patients with CWSs and Roth spots had a
mortality rate 8 times higher than those without
Age >40 incurred a 7 times higher mortality risk
References
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Ling R, James B. White-centered retinal hemorrhages (Roth spots). Postgrad
Med J. 1998 Oct; 74(876):581-582.
Guyer DR, Schachat AP, Vitale S, et al. Leukaemic retinopathy.
Relationship between fundus lesions and haematologic parameters at
diagnosis. Ophthalmology. 1980;87:66-9
Abu el-Asrar AM, al-Mornen AK, Kangave D, Harakati MS. Prognostic
importance of retinopahy in acute leukemia. Doc Ophthalmol. 1995;91(3):27381.
Carraro MC, Rossetti L, Gerli GC. Prevalence of retinopathy in patients
with anemia or thrombocytopenia. Eur J Haematol. 2001 Oct;67(4):238-44.
BCSC Ophthalmologic Pathology and Intraocular Tumors. pp160-161
Macauley M, Nag S. Roth spots in pernicious anemia. BMJ Case Reports.
2011;doi:10.