Sir,

We present a case of Roth spots in multiple myeloma and describe optical coherence tomography (OCT) findings that have not previously been published.

Case report

A 42-year-old woman with multiple myeloma presented with ‘inability to see faces’. Her best-corrected visual acuity was counting fingers in the right eye and 20/200 in the left eye. Although the anterior segment was unremarkable, fundus examination showed bilateral, white-centered hemorrhages, and subhyaloid hemorrhages in both the maculae (Figure 1a). Spectral-domain OCT (SD-OCT) confirmed the location of the subhyaloid hemorrhage and showed a unique finding of cystic spaces surrounding the hemorrhages, more evident on near infrared images (Figure 1b). The greatest ‘shadowing effect’ seen centrally on SD-OCT corresponded to the area of the ‘white centers’ in Roth spots. The SD-OCT also showed small cystic spaces within the outer plexiform layer (Figure 1c, left). Laboratory testing revealed WBC 123.8 (4.5–11.0), RBC 10.7 (4.20–5.40), hematocrit 10.6 (37.0–47.0), and platelet 22 (140–440). Serum creatinine and calcium were within normal.

Figure 1
figure 1figure 1

Color fundus photograph (a) of both eyes (left and right panels) from a patient with multiple myeloma showing intraretinal and subhyaloid hemorrhages with Roth spots; near infrared images (b) in the corresponding areas of both eyes—also showing the section for the SD-OCT images (c) obtained at baseline in both eyes (c) and at 2-weeks follow-up (d) in the right eye only.

Full size image

Comment

Multiple myeloma, a neoplastic plasma cell dyscrasia, is considered symptomatic when it causes tissue dysfunction including hypercalcemia, renal insufficiency, anemia, and bone disease.1 Retinal manifestations include intraretinal and flame-shaped hemorrhages, some of which contain white centers2 (Roth spots), microaneurysms, signs of hyperviscosity syndrome, and serous/exudative retinal detachment.3, 4 Myeloma-related retinopathy has been significantly related to lower hemoglobin and platelet levels, as in our patient. The Roth spots are commonly seen in subacute bacterial endocarditis, trauma, blood dyscrasias, acute lowering of intraocular pressure, anemia, and anoxic conditions.5

The flame-shaped hemorrhages in the nerve fiber and ganglion cell layers correlate with the location as shown in the SD-OCT. The unique finding of large cystic spaces just adjacent and surrounding the subhyaloid hemorrhage suggests the presence of possibly ‘serum’ in those cystic spaces, which decreases in size as the hemorrhage is resolving (Figure 1d). The SD-OCT also identified cysts in the outer plexiform layer, which have not been reported before. Based on our literature review, this is the first description of Roth spots as visualized by SD-OCT, providing us more insight into the pathophysiology of the condition and serve as an excellent tool in monitoring these hemorrhages.