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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 Subacute bacterial endocarditis Anemia Leukemias Diabetes HTN Sepsis Labs 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 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 Chemo not initiated due to comorbidities Palliative 5 day course of Decitabine initiated Roth Spot 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 Retinal capillary rupture Extrusion of whole blood Platelet adhesion and activation Coagulation cascade Platelet-fibrin thrombus Subacute Bacterial Endocarditis 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 Ocular findings in about 40% Positive correlation between levels of anemia and/or thrombocytopenia Exam 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 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 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 1. 2. 3. 4. 5. 6. 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.