Blot Hemorrhages Research Articles

Ophthalmic Complications of Dengue

We report 13 cases of ophthalmic complications resulting from dengue infection in Singapore. We performed a retrospective analysis of a series of 13 patients with dengue fever who had visual impairment. Investigations included Humphrey automated visual field analyzer, Amsler charting, fundus fluorescein angiography, and optical coherence tomography. Twenty-two eyes of 13 patients were affected. The mean age of patients was 31.7 years. Visual acuity varied from 20/25 to counting fingers only. Twelve patients (92.3%) noted central vision impairment. Onset of visual impairment coincided with the nadir of serum thrombocytopenia. Ophthalmologic findings include macular edema and blot hemorrhages (10), cotton wool spots (1), retinal vasculitis (4), exudative retinal detachment (2), and anterior uveitis (1). All patients recovered visual acuity to 20/30 or better with residual central scotoma by 12 weeks. These new complications suggest a widening spectrum of ophthalmic complications in dengue infection.

Ocular manifestations of crush head injury in children

To review the ocular manifestations of crush head injuries in children. Retrospective clinical and pathological reviews. Group 1: A total of 16 children admitted with crush head injuries from television tip over. Group 2: Nine autopsy findings in crush head injury. Group 1: A total of 11 children had fundus examination: three by neurosurgeons, eight by ophthalmologists. Scattered posterior pole preretinal and blot haemorrhages extending to mid equator region observed in one child. No evidence of traumatic retinoschisis or retinal folds in any patient. Group 2: All with multiple skull fractures and six with subdural haemorrhage. Posterior pole retinal haemorrhages in four children, extending to the ora serrata in one after motor vehicle accident. No child had retinal folds. Subinternal limiting membrane haemorrhages in three children. Optic nerve sheath haemorrhage in three children. Intraretinal and preretinal haemorrhages, predominantly in the posterior pole, can occur in crush injury to the paediatric head. Haemorrhage under the internal limiting membrane or extending to the ora serrata were only seen in situations where crush injury was part of a fatal trauma scenario related to motor vehicles. Retinal folds and the typical macular retinoschisis associated with abusive head injury were not observed.

Retinal Microvascular Abnormalities and MRI-Defined Subclinical Cerebral Infarction

Retinal microvascular abnormalities reflect cumulative small vessel damage from elevated blood pressure and may reflect subclinical cerebral microvascular changes. We examined their associations with MRI-defined cerebral infarcts. Population-based, cross-sectional study of 1684 persons 55 to 74 years of age without a history of clinical stroke, sampled from 2 US southeastern communities. Retinal photographs were obtained and graded for presence of retinal microvascular abnormalities, including arteriovenous nicking, focal arteriolar narrowing, retinal hemorrhages, soft exudates and microaneurysms. Photographs were also digitized, and retinal vessel diameters were measured and summarized as the arteriole-to-venule ratio (AVR). Cerebral MRI scans were graded for presence of cerebral infarct, defined as a lesion > or =3 mm diameter in a vascular distribution with typical imaging characteristics. There were a total of 183 MRI cerebral infarcts. After adjustment for age, gender, race, 6-year mean arterial blood pressure, diabetes, and other stroke risk factors, cerebral infarcts were associated with retinal microvascular abnormalities, with odds ratios 1.90 (95% CI, 1.25 to 2.88) for arteriovenous nicking, 1.89 (95% CI, 1.22 to 2.92) for focal arteriolar narrowing, 2.95 (95% CI, 1.30 to 6.71) for blot hemorrhages, 2.08 (95% CI, 0.69, 6.31) for soft exudates, 3.17 (95% CI, 1.05 to 9.64) for microaneurysms, and 1.74 (95% CI, 0.95 to 3.21) for smallest compared with largest AVR. In stratified analyses, these associations were only present in persons with hypertension. Retinal microvascular abnormalities are associated with MRI-defined subclinical cerebral infarcts independent of stroke risk factors. These data suggest that retinal photography may be useful for studying subclinical cerebrovascular disease in population-based studies.

Trombocitemia esencial y trombosis venosa retiniana

Essential thrombocytosis is a disorder of the hematopoietic stem cell that causes proliferation of platelets. We report two cases: a 72-year-old woman with ischemic retina and tortuous and white veins in the superior retina and diffuse hemorrhages in the inferior retina with blot hemorrhages scattered throughout the equatorial region in the left eye; and a 62-year-old man with a central retinal vein occlusion in the left eye as signs of essential thrombocythemia. These cases are examples of potential complications of essential thrombocytosis. Vulnerable patients should be monitored for retinal vascular occlusions, especially when platelet counts do not exceed 106/mm3.

Hypertensive retinopathy

A 20-year-old woman presented with an acute decrease of visual acuity in both eyes. She had noticed the decrease over the past 24 h and had a 1 week history of arthralgias, headaches, and angina without fever. On examination the patient had a reduced visual acuity of 20/100 in both eyes. Fundus examination showed diffuse cotton-wool spots, narrow arterioles, some blot haemorrhages and an exudative maculopathy with otherwise normal anterior findings (figure, top).

Wong TY, Klein R, Couper DJ, et al. Retinal microvascular abnormalities and incident stroke: the Atherosclerosis Risk in Communities Study.

Wong TY, Klein R, Couper DJ, et al. Retinal microvascular abnormalities and incident stroke: the Atherosclerosis Risk in Communities Study. Lancet 2001;358:1134–40. Wong et al. obtained undilated retinal photographs in 10,358 men and women living in North Carolina, Mississippi, Minnesota, and Maryland. They followed the patients for an average of 3.5 years (range 3–5 years), and observed the frequency of stroke (ischemic or hemorrhagic), stratifying it with respect to retinal vessel abnormalities, predisposing systemic diseases (diabetes, hypertension, coronary artery disease), and other risk factors (smoking, alcohol use, cholesterol). There were 110 patients with stroke (96 ischemic, 13 hemorrhagic, and one ischemic/hemorrhagic). After adjusting for age, gender, race, and locality, each of the retinal microvascular lesions observed increased the relative risk of stroke above baseline (microaneurysm: RR 5.0 [95% CI 3.0–8.2], soft exudates: 5.6 [2.8–89], blot hemorrhage: 4.9 [2.7–8.8], flame hemorrhage: 4.6 [2.1–9.9], arteriovenous nicking: 1.9 [1.3–3.0]). Much of this could be expected because these lesions are commonly associated with hypertension, diabetes, and other vascular diseases, and these diseases are all risk factors for stroke. Surprisingly, when a multivariate analysis was done, adjusting for blood pressure, the use of antihypertensive medications, the presence of diabetes, smoking status, fasting glucose, and blood lipid measurements, each of the retinal abnormalities was still a significant risk factor for stroke, although to a lesser degree. A stratified analysis using the presence of diabetes and hypertension also showed that the retinal abnormalities were independent predictors of stroke, although the small number of patients in some of the groups meant that the confidence limits were wide. The biggest potential flaw of this study is that the confounding variables (presence of hypertension and other vascular diseases may not have been completely eliminated in the multivariate analyses. Nonetheless, an important implication of this study is that observation of a retinal microvascular abnormality in a patient should not only prompt a work-up for vascular disease, but even if no disease is present, suggest that the patient is at an increased risk of stroke. The retinal abnormalities may be markers of small vessel disease and may be indicative of vascular pathologic processes occurring in the cerebral circulation.

Rubeosis Iridis

A 70-year-old-man presented following the subacute onset of loss of vision in his right eye. In the previous weeks he had also experienced a dull ache around the right eye...

Retinal microvascular abnormalities and incident stroke: the Atherosclerosis Risk in Communities Study

Retinal microvascular abnormalities reflect damage from hypertension and other vascular processes. We examined the relation of such abnormalities to incident stroke. A cohort of 10358 men and women (aged 51 to 72 years) living in four US communities underwent retinal photography and standard grading for retinal microvascular abnormalities. The calibres of all retinal arterioles and venules were measured after digital conversion of the photographs, and a summary arteriole-to-venule ratio (AVR) was calculated as an index of arteriolar narrowing (smaller AVR indicates greater narrowing). Cases of incident stroke admitted to hospital were identified and validated by case record reviews. Over an average of 3.5 years, 110 participants had incident strokes. After adjustment for age, sex, race, 6-year mean arterial blood pressure, diabetes, and other stroke risk factors, most retinal microvascular characteristics were predictive of incident stroke, with adjusted relative risks of 2.58 (1.59-4.20) for any retinopathy, 3.11 (1.71-5.65) for microaneurysms, 3.08 (1.42-6.68) for soft exudates, 2.55 (1.27-5.14) for blot haemorrhages, 2.26 (1.00-5.12) for flame-shaped haemorrhages, and 1.60 (1.03-2.47) for arteriovenous nicking. The relative risk of stroke increased with decreasing AVR (p=0.03). The associations were similar for ischaemic strokes specifically, and for strokes in individuals with hypertension, either with or without diabetes. Retinal microvascular abnormalities are related to incident stroke. The findings support a microvascular role in the pathogenesis of stroke. They suggest that retinal photography may be useful for cerebrovascular-risk stratification in appropriate populations.

Telemedicine Screening of Diabetic Retinopathy Using a Hand-Held Fundus Camera

The objective was to evaluate digital images of the retina from a handheld fundus camera (Nidek NM-100) for suitability in telemedicine screening of diabetic retinopathy. A handheld fundus camera (Nidek) and a standard fundus camera (Zeiss) were used to photograph 49 eyes from 25 consecutive patients attending our diabetic clinic. One patient had cataracts, making it impossible to get a quality image of one of the eyes (retina). The Nidek images were digitized, compressed, and stored in a Fujix DF-10M digitizer supplied with the camera. The digital images and the photographs were presented separately in a random order to three ophthalmologists. The quality of the images was ranked as good, acceptable or unacceptable for diabetic retinopathy diagnosis. The images were also evaluated for the presence of microaneurysms, blot hemorrhages, exudates, fibrous tissue, previous photocoagulation, and new vessel formation. kappa Values were computed for agreement between the photographs and digital images. Overall agreement between the photographs and digital images was poor (kappa < 0.30). On average, only 24% of the digital images were graded as being good quality and 56% as having an acceptable quality. However, 93% of the photographs were graded as good-quality images for diagnosis. The results indicate that the digital images from the handheld fundus camera may not be suitable for diagnosis of diabetic retinopathy. The images shown on the liquid crystal display (LCD) screen of the camera were of good quality. However, the images produced by the digitizer (Fujix DF-10M) attached to the camera were not as good as the images shown on the LCD screen. A better digitizing system may produce better quality images from the Nidek camera.

A comparison of digital nonmydriatic fundus imaging with standard 35-millimeter slides for diabetic retinopathy

Purpose The purpose of this study was to compare nonmydriatic digital images with 35-mm slide images for the detection of diabetic retinal findings. Study design Comparative, observational case series. Participants Forty patients with diabetes. Methods Diabetic patients underwent digital (nonmydriatic fundus camera attached to a digital back) and standard dilated 35-mm retinal photography of three areas: posterior pole, nasal retina, and temporal retina. The images were reviewed by a single masked grader for the presence or absence of specific retinal findings. Primary outcome measures Presence or absence of neovascularization of the disc (NVD), neovascularization elsewhere (NVE), venous beading (VB), nerve fiber layer (NFL) hemorrhage, dot–blot hemorrhage, microaneurysm (MA), clinically significant macular edema, cotton wool spot, intraretinal microvascular anomaly (IRMA), hard exudate (HE), and retinal pigment epithelial (RPE) pigmentary changes. Results Forty eyes of 22 patients underwent both imaging procedures. The agreement between image type was highest for IRMA (97.5%) and VB (95%) and lowest for RPE pigmentary changes (65%) and MA (62.5%). Sensitivity ranged from 25% (NVD) to 100% (VB). Specificity ranged from 90% (RPE pigmentary changes) to 100% (NVD, NVE, VB, NFL hemorrhage, HE). Positive predictive value ranged from 50% (IRMA) to 100% (NVD, NVE, HE, NFL, VB). Negative predictive value ranged from 48% (MA) to 100% (IRMA). Conclusions Nonmydriatic digital fundus imaging for detection of diabetic retionopathy has a low sensitivity rate and a high specificity rate and is less clinically useful than standard dilated 35-mm fundus slide images.

Retinal manifestations of HIV-1 and HIV-2 infections among hospital patients in The Gambia, west Africa.

In developed countries, 50-75% of AIDS patients develop retinal complications and about 20-40% acquire cytomegalavirus (CMV) retinitis. We conducted a cross-sectional survey to determine prevalence of these in The Gambia where both HIV-1 and HIV-2 infection are present and the prevalence of HIV-1 is rising. All patients attending hospital whose percentage CD4+ cells (CD4%) was below 14, the level associated typically with an AIDS diagnosis, and one half of those whose CD4% was 14 or above were asked to join the study. Fifty-six HIV-1, 52 HIV-2 and 12 dually infected patients were recruited. Photographs of the fundi were taken and interpreted independently. The findings were related to the patients' percentage CD4+ cells. The CD4% was < 14 in 40 patients and < 7 in 17 patients. Thirty-six patients were male. No cases of CMV retinitis were found. Four patients whose CD4% were 4, 5, 11 and 23 had cotton wool spots ranging in number from 1 to 14 for any one patient. The prevalence of cotton wool spots was 8% (95% CI, 0-16%) among patients with CD4% below 14 and 12% (95% CI, 0-27) among patients with CD4% below 7. One of the 4 patients had associated microaneurysm and blot haemorrhages typical of more advanced HIV microvasculopathy. CMV retinitis is less common in The Gambia than in developed countries. Non-infectious retinopathy may also be less common.

The relation of systemic hypertension to changes in the retinal vasculature: the beaver dam eye study: Klein R *, Klein BEK, Moss SE. Trans Am Ophthalmol Soc 1997;95:329–348

The objective was to investigate the relationship of systemic hypertension to the incidence of various retinal vascular lesions in the population-based Beaver Dam Eye Study.Subjects aged 43 through 86 years who lived in Beaver Dam, Wisconsin between 1987 and 1988 were examined between 1988 and 1990 and 5 years later, 1993-1995. Blood pressure was measured using standardized protocols. Stereoscopic color fundus photographs were graded in a masked fashion using standardized protocols to determine the presence of retinopathy (blot hemorrhages, microaneurysms, hard and soft exudates, intraretinal microvascular abnormalities, and venous beading), retinal arteriolar narrowing, and arterio-venous nicking. People with diabetes or retinal vascular occlusions were excluded from the analyses.Among those examined, 2,151 (69.1%) were normotensive and 963 (30.9%) were hypertensive at baseline. Over the five-year period, retinopathy developed in 175 (6.0%), arteriolar narrowing in 282 (9.9%) and arterio-venous nicking in 201 (6.5%) nondiabetic subjects. After adjusting for age, hypertension was associated with the incidence of retinopathy (in men: relative risk [RR] 2.31, 95% confidence interval [CI] 1.54 to 3.48; in women: RR 1.61, 95% CI 1.07 to 2.43) and with arteriolar narrowing (in men: RR 1.82, 95% CI 1.25 to 2.66; in women: RR 1.36, 95% CI 1.05 to 1.77), but not with arterio-venous nicking (in men: RR 1.01, 95% CI 0.69 to 1.48; in women: RR 1.37, 95% CI 0.95 to 1.97). The five-year incidence of retinopathy and of arteriolar narrowing was higher in those subjects whose blood pressure was elevated despite use of antihypertensive medications compared with those subjects whose blood pressure was controlled with antihypertensive medications or those who were normotensive.These data show a relation of hypertension to an increased incidence of retinopathy and arteriolar narrowing. Furthermore, these data suggest that pharmacologic control of blood pressure is related to a lower incidence of these anatomic retinal lesions relative to uncontrolled blood pressure.

Thrombotic thrombocytopenia purpura (TTP) associated retinopathy: Case report and literature review

Thrombotic thrombocytopenia purpura is a rare condition characterized by a pentad of clinical signs that include thrombocytopenia, microangiopathic hemolytic anemia, fluctuating neurologic dysfunction, renal failure and fever. The microangiopathic changes occurring in TTP may also result in ocular manifestations. We present a case of a patient diagnosed with TTP whose ocular findings include macular exudation, cotton wool spots, intraretinal microvascular abnormalities, blot haemorrhages and serous macular detachment.

Retinal hemodynamics in patients with hyperviscosity syndrome

The hyperviscosity syndrome (e.g. plasmacytoma, cryoglobulinaemia and Waldenström's macroglobulinaemia) leads through the polymerisation of macro-molecules to an increased blood viscosity. This may result in microcirculatory disturbances in various organs. In the retina the hyperviscosity produces a pattern of retinal changes including dot and blot hemorrhages, retinal and optic nerve head edema and increased diameters of the veins. In the present study we quantified the retinal hemodynamic in patients with hyperviscosity syndrome. Fifteen patients aged between 35 and 72 years were included in the study. Ten presented with Waldenström's macroglobulinaemia, two with cryoglobulinaemia and three with plasmacytoma. All patients underwent video fluorescein angiographic studies. The arteriovenous passage time (AVP) representing the retinal microcirculation and the arm retina time (ART) were quantified from the angiograms. In addition, hematocrit (Hct) and the plasma viscosity (ETA) were measured. The AVP was significantly prolonged in patients with hyperviscosity syndrome in comparison to healthy volunteers (AVP: 2.6 +/- 1.5 s vs. 1.6 +/- 0.4 s; p < 0.05). The ART showed no significant differences. Plasma viscosity was doubled in the patients as compared with reference values (ETA: 2.54 +/- 2.23 mPas vs. 1.24 +/- 0.08 mPas; p < 0.01). The simultaneous rising of plasmaviscosity and arteriovenous passage time suggests that the increase of plasmaviscosity causes retinal circulatory disturbance. All this may result in the typical fundus changes in patients with hyperviscosity syndrome.

Diabetic retinopathy and control of diabetes with special reference to blood glucose levels

Data concerning diabetic retinopathy were collected prospectively in the Diabetes Clinic of the Third Department of Internal Medicine, University of Tokyo, from the beginning of the Clinic in 1957 until 1985. These data are analyzed here. The prevalence and severity of the retinopathy at the initial visit was strongly related to the duration of diabetes before examination. Pretreatment fasting blood glucose levels were also significantly related. During follow-up, the incidence of retinopathy was most strongly influenced by the degree of control of blood glucose, followed by other factors like blood pressure, age at diagnosis, etc. The effectiveness of sulfonylurea on retinopathy was not inferior to insulin so long as good control was obtained. It was deduced from the analysis of the chain of events that dot hemorrhage is the initial component of diabetic retinopathy, followed by hard exudate, blot hemorrhage, soft exudate and proliferative retinopathy. A six-year fluorescein angiography follow-up of well-controlled non-insulin dependent cases with mild retinopathy showed that microaneurysms disappear rapidly during the first year and more slowly thereafter. The avascular areas once formed seem to progress despite the degree of control exerted here. The other Japanese results are discussed.

Chronic Ocular Ischemia Associated With the Eisenmenger's Syndrome

We studied the ocular findings of two adult patients with the Eisenmenger's syndrome who had atrial septal defects that were diagnosed before the age of 10 years but not operated on and pulmonary hypertension. Both eyes of these patients showed microaneurysms, multiple small blot hemorrhages, or capillary dilation in the temporal peripheral fundus. Multiple microaneurysms and retinal collaterals were confirmed by fluorescein angiography. One of the patients developed bilateral rubeosis iridis with slow progression. These retinal lesions and the rubeosis iridis are probably related to chronic ocular ischemia caused by chronic systemic hypoxia.

Hypertension and retinopathy, arteriolar narrowing, and arteriovenous nicking in a population.

To investigate the relationship of various retinal lesions to systemic hypertension in the population-based Beaver Dam Eye Study. In this cross-sectional population-based study, blood pressure was measured using standardized protocols. Using standardized protocols, stereoscopic color fundus photographs were graded in a masked fashion to determine the presence of retinopathy (defined as retinal microaneurysms only, blot hemorrhages only, hemorrhages and/or microaneurysms, cotton-wool spots, hard exudates, intraretinal microvascular abnormalities, venous beading, and retinal new vessels), retinal arteriolar narrowing, and arteriovenous nicking. Subjects aged 43 through 84 years who lived in Beaver Dam, Wis, between 1987 and 1988 were examined between 1988 and 1990. People with diabetes or retinal vascular occlusions were excluded. Retinopathy was present in 336 subjects (7.8%), arteriolar narrowing in 582 subjects (13.5%), and arteriovenous nicking in 95 subjects (2.2%) in the nondiabetic population. Hypertension was associated with increased frequency of retinopathy, arteriolar narrowing, and arteriovenous nicking. After adjusting for age, hypertension was associated with the presence of retinopathy (in men: relative risk [RR], 1.47; 95% confidence interval [CI], 1.10 to 1.96; in women: RR, 1.69; 95% CI, 1.26 to 2.27), arteriolar narrowing (in men: RR, 1.34; 95% CI, 1.03 to 1.74; in women: RR, 1.37; 95% CI, 1.14 to 1.64), and arteriovenous nicking (in men: RR, 1.87; 95% CI, 0.99 to 3.54; in women: RR, 1.65; 95% CI, 1.00 to 2.73). Retinopathy, arteriolar narrowing, and arteriovenous nicking were more frequent in those subjects whose blood pressure was elevated despite use of antihypertensive medications compared with those subjects whose blood pressure was controlled with antihypertensive medications or those who were normotensive. These data suggest that retinopathy and retinal arteriolar narrowing are common in people with hypertension. Further longitudinal study is necessary to evaluate the public health significance of these retinal lesions regarding possibly increased risk of renal and cardiovascular disease.

Acquired Retinal Arteriovenous Communications in Occlusive Disease of the Carotid Artery

Retinal arteriovenous communications proximal to extensive areas of complete vascular closure developed in three patients with occlusive disease of the carotid arteries. In one case, the authors document the development of the arteriovenous communications through successive enlargement of small retinal vessels after progressive signs of retinal ischemia in the form of narrowed retinal arteries, venous dilation and beading, microaneurysms, retinal dot and blot hemorrhages, cotton-wool spots, and capillary nonperfusion. The development of arteriovenous communications in carotid occlusive disease has not been described previously.

High blood pressure as risk factor in diabetic retinopathy development in NIDDM patients.

The correlation between diabetic retinopathy and blood pressure was analyzed in 742 type II diabetic patients. Systolic and pulse blood pressures were significantly higher in the patients with retinopathy than in those without (mean systolic pressure 142 vs. 139 mmHg, P less than .01; mean pulse pressure 60.5 vs. 56.4 mmHg, P less than .001). There was no difference in the diastolic blood pressure between these two groups. The correlation between blood pressure and the components of retinopathy (including microaneurysms, hemorrhages, and exudates) was also analyzed. Even when the patient with microaneurysms or dot hemorrhages, blot hemorrhages, or hard or soft exudates were separately evaluated, systolic and pulse blood pressures were higher in those with one of these diabetic changes than in patients without them. To avoid the influence of nephropathy, the patients were divided into nonproteinuric or proteinuric groups. In the nonproteinuric group, pulse blood pressure was higher in patients with retinopathy than in those without. In the proteinuric group, systolic blood pressure was also higher in patients with retinopathy than in those without. However, these observed differences in blood pressure were slight after the division of the patients. With respect to the components of retinopathy, systolic and pulse blood pressures were significantly higher in the patient with blot hemorrhages than in those without in both nonproteinuric and proteinuric groups (nonproteinuric: systolic pressure 142 vs. 137 mmHg, P less than .005, and pulse pressure 60.4 vs. 55.5 mmHg, P less than .001; proteinuric: systolic pressure 155 vs. 146 mmHg, P less than 0.01, and pulse pressure 69.0 vs. 63.5 mmHg, P less than .05).

Pattern electroretinograms become abnormal when background diabetic retinopathy deteriorates to a preproliferative stage: possible use as a screening test.

The pattern electroretinogram (PERG) and other tests were given to a selected group of patients with diabetes, ranging from those who had no retinopathy or funduscopic changes to those in the preproliferative state. None had visual symptoms. The PERG was found to be normal in patients with microaneurysms and a few blot haemorrhages. However, when cotton-wool spots and angiographic evidence of areas of capillary non-perfusion were present, the PERG was reduced below the normal value. Similar changes occurred with the oscillatory potentials of the ERG evoked by an intense flash, but the results were more variable. So in the individual patient the test is not a reliable indicator of the progress of the retinopathy. The value of the PERG in screening is discussed.