White-Centered Retinal Hemorrhages

During a hospital stay, a 52-year-old woman presented to the inpatient ophthalmology consultation service with a 1-week history of floaters in the right eye. She had been admitted 1 week earlier for severe dehydration and fever, and Candida albicans fungemia had been diagnosed. Her past medical history included gastric bypass surgery, hypertension, Clostridium difficile infection, and methicillin-resistant Staphylococcus aureus bacteremia.

Visual acuity was 20/25 and 20/20 in the right and left eyes, respectively. Slit lamp examination showed minimal nuclear sclerotic cataracts. Funduscopic examination revealed numerous white-centered retinal hemorrhages bilaterally (A, asterisks and B), peripheral choroidal/deep retinal infiltrates (A, black arrows and C), and perifoveal chorioretinal infiltrates with overlying areas of focal vitreous inflammation in the right eye (A, white arrows) as documented by optical coherence tomography (D, yellow arrow). The posterior face of the vitreous body is shown with white arrows in D.

These findings were consistent with a diagnosis of endogenous fungal endophthalmitis. The patient was successfully treated with intravenous fluconazole and, later, with oral fluconazole.

White-centered retinal hemorrhages are associated with a myriad of systemic conditions; among the most common are anemia, thrombocytopenia, hypertension, diabetes, leukemia, HIV infection, fungemia, bacteremia, and subacute bacterial endocarditis.^1,2 In the last setting, these hemorrhages are often referred to as Roth spots. Patients who present with white-centered retinal hemorrhages require a prompt comprehensive evaluation to determine the cause.

At follow-up 2 months later, visual acuity remained 20/25 and 20/20 in the right and left eye, respectively, and the patient was asymptomatic with complete resolution of the hemorrhages and endophthalmitis.