Eye Signs of Systemic Disease: Case 2 Cotton-Wool Spot

A 49-year-old woman presented for aroutine eye examination. She had nohistory of systemic disease and tookno medications.The patient's best correctedvisual acuity in each eye was 20/20.Ophthalmic evaluation was unremarkableexcept for a single area ofwhitish opacification along the supratemporalarcade vessels in the lefteye. The ovoid lesion with somewhatnondistinct borders appeared to overliethe retinal vasculature (A). Noother abnormalities, such as emboli,edema, hemorrhage, or hard exudate,were noted.This patient has a cotton-woolspot, also called a soft exudate or acystoid body. These areas of superficialwhitening arise in the nerve fiberlayer of the retina as a result of capillaryinfarction. They may occur singlyor as multiple scattered spots in theposterior pole along the distribution ofthe radial peripapillary capillaries orthe retinal vascular arcades. Cottonwoolspots are transient; however, anarea of focal fibrosis can be left behindafter the spots resolve (B).Cotton-wool spots can develop inpersons who sustain trauma to theretina. They are also associated withdiabetic retinopathy; malignant hypertensiveretinopathy; collagen vasculardiseases, such as systemic lupus erythematosus;giant cell arteritis; carotidartery disease with emboli; cardiacvalvular diseases with emboli; retinalvein or retinal artery occlusions; ocular ischemic syndrome;radiation retinopathy; anemia; leukemia; papilledema;generalized carcinomatosis; and AIDS.Cotton-wool spots are the most characteristic sign ofAIDS-related retinopathy and are seen in many AIDSpatients. The lesions are not generally associated with secondaryretinal infection.This patient's blood pressure, fasting glucose and antinuclearantibody levels, and other laboratory results were normal. Results of a transesophageal echocardiogram andof a thalium stress test were also normal. Carotid duplexultrasonography demonstrated a 40% left internal carotidartery stenosis. The patient was referred to a vascular specialistfor further evaluation.