Dots spots lines and rings in ophthalmology

SPOTS,DOTS ,LINES
AND RINGS IN
OPHTHALMOLOGY
COMPILED BY
DR.PRAVIN M BHAT
CONSULTING OPHTHALMOLOGIST
PRATHAMESH EYE CLINIC, PUNE

BITOT'S SPOTS
 These are the buildup of keratin located superficially in the
conjunctiva, which are oval, triangular or irregular in shape.
These spots are a sign of vitamin A deficiency and are
associated with conjunctival xerosis. In 1863,
Pierre Bitot (1822-1888), a French physician, first
described these spots.
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BRUSHFIELD SPOT
 Brushfield spots are small, white or grayish/brown spots on
the periphery of the iris in the human eye due to aggregation
of connective tissue, a normal iris element.
 The spots are named after the physician Thomas Brushfield,
who first described them in his 1924 M.D. thesis.
 These spots are normal in children (Kunkmann-Wolffian
bodies), but are also a feature of the chromosomal
disorder Down syndrome.
 They occur in 35–78% of newborn infants with Down
syndrome. They are much more likely to occur in children
with Down syndrome of European descent than children
of Asianheritage with Down's Syndrome.
 They are focal areas of stromal hyperplasia, surrounded by
relative hypoplasia, and are more common in patients with
lightly pigmented irises.
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BRUSHFIELD SPOT
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ELSCHNIG SPOT
 Elschnig's spots are black spots surrounded by bright
yellow or red halos seen on
the retina during fundoscopy in patients with
advanced hypertensive retinopathy. They are named
after Anton Elschnig.
 Elschnig spots are commonly caused by acute
hypertensive events of the choroidal vascular system,
mostly in the young, because their system of vessels is
not ready to handle the changes in blood pressure.
 These changes in blood pressure cause an infarct of the
vessels leading to death of the RPE and photoreceptors
they support creating this window defect.[1]
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FISCHER-KHUNT SPOT
 Senile Scleral Paque, area of Hyalinised Sclera Anterior
to Horizontal Rectus Muscle Insertion, seen in Old Age.
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FUCH'S SPOT
 The Fuchs spot or sometimes Forster-Fuchs' retinal
spot is a degeneration of the macula in case of
high myopia.
 It is named after the two persons who first described
it: Ernst Fuchs, who described a pigmented lesion in
1901, and Forster, who described subretinal
neovascularisation in 1862.
 The size of the spots are proportionate to the severity of
the pathological myopia.
 First signs of a Fuchs spot are distorted sight of straight
lines near the fovea, which some days later turn to the
typical well-circumscribed patches after absorption of
haemorrhage, and a pigmented scar remains.
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ROTH SPOTS
 Roth's spots are retinal hemorrhages with white or pale
centers.
 The original retinal spots identified in 1872 were attributed to
nerve-fibres that had burst or exploded.
 Present-day analysis shows that they can be composed
of coagulated fibrin including platelets, focal ischemia,
inflammatory infiltrate, infectious organisms, or neoplastic cells.
 They are typically observed via fundoscopy (using
an ophthalmoscope to view inside the eye) or slit lamp exam.
 They are usually caused by immune complex mediated
vasculitis often resulting from bacterial endocarditis.
 Roth's spots may be observed in leukemia, diabetes, subacute
bacterial endocarditis, pernicious anemia, ischemic
events, hypertensive retinopathy and rarely in HIV retinopathy.
 Roth's spots are named after Moritz Roth.
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KRACHMER SPOT
 Subepithelial rejection is characterized by subepithelial
infiltrates, reminiscent of adenoviral infection (Krachmer
spots) on the donor cornea, with deeper oedema and
infiltrative opacification.
 Stromal rejection features deeper haze. It can be chronic
or hyperacute, the latter in association with endothelial
rejection.
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LEOPARD SPOT
 Patchy subretinal infiltrate appears in reticular cell
carsinoma, CSR and other conditions of retina.
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HISTO SPOTS
 A small circular punched-out spot in the retina at a site
where spores of the fungus histoplasma (histo) seeded in
the eye.
 Histo spots may be multiple, found in both eyes, and
scattered throughout the retina. Can be seen in presumed
ocular histoplasmosis syndrome (POHS).
 Histo spots in the macula are significant since they may
stimulate the growth of abnormal new blood vessels
located under the retina.
 These new blood vessels may suddenly bleed, causing
permanent macular scarring and impairing central vision.
 If the process is detected at an early stage, it may be
successfully treated with focal retinal laser.
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COTTON WOOL SPOTS
 Cotton wool spots are an abnormal finding
on funduscopic exam of the retina of the eye.
 They appear as fluffy white patches on the retina. They are
caused by damage to nerve fibers and are a result of
accumulations of axoplasmic material within the nerve fiber
layer.
 There is reduced axonal transport (and hence backlog and
accumulation of intracellular products) within the nerves
because of the ischemia. This then causes the nerve fibers to
be damaged by swelling in the surface layer of the retina.
 A 1981 analysis concluded that "in most instances, cotton-wool
spots do not represent the whole area of ischaemic inner retina
but merely reflect the obstruction of axoplasmic flow in axons
crossing into much larger ischaemic areas".
 Associated findings include microvascular infarcts and
hemorrhages. The appearance of cotton wool spots may
decrease over time. Abundant cotton wool spots are seen in
Malignant hypertension.
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COTTON WOOL SPOTS
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CHERRY RED SPOT
 A cherry-red spot is a finding in the macula of the eye in a
variety of lipid storage disorders and in central retinal artery
occlusion.
 It describes the appearance of a small circular choroid shape
as seen through the fovea centralis.
 Its appearance is due to a relative transparency of the macula;
storage disorders cause the accumulation of storage material
within the cell layers of the retina, however, the macula, which
is relatively devoid of cellular layers, does not build up this
material, and thus allows the eye to see through the macula to
the red choroid below.
 The sign was first described by Warren Tay, founding member
of the British Ophthalmological Society, in 1881, with reference
to a patient with Tay–Sachs disease.
 The cherry red spot is seen in central retinal artery occlusion,
appearing several hours after the blockage of the retinal
artery occurs.
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CHERRY RED SPOT
 The cherry red spot is seen because the macula receives
its blood supply from the choroid, supplied by the
posterior ciliary arteries, while the surrounding retina is
pale due to retinal artery infarction.
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CREAM COLOURED SPOT
 The classic diagnostic feature of birdshot vitiligenous
chorioretinitis is cream colored spots, often as large as
0.5 to 1 disc diameter, that are scattered throughout the
fundus.
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KOPLIK’S SPOT
 Koplik spots (also Koplik's sign) are
a prodromic viral enanthem of measles manifesting two to
three days before the measles rash itself.
 They are characterized as clustered, white lesions on
the buccal mucosa (opposite the lower 1st & 2nd molars),
conjunctiva and are pathognomonic for measles.
 The textbook description of Koplik spots is ulcerated
mucosal lesions marked by necrosis, neutrophilic
exudate, and neovascularization.
 They are described as appearing like "grains of salt on a
wet background“, and often fade as the maculopapular
rash develops.
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KOPLIK’S SPOT
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GUNN'S DOT
 Gunn's dots, originally described by Marcus Gunn, are
tiny white dots sometimes visible overlying the large
vessels near the optic nerve or the nerve fiber layers.
 Their presence depends on lighting conditions, and they
have no pathologic significance.
 They are visible reflections of the internal limiting
membrane, created by the footplate of the Muller cells.
 The tiny white specks in these photos are best visualized
at the 12:00 and 6:00 positions approximately 1 disc
diameter from the optic nerve head.
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HORNER-TRANTRAS DOT
 There is thickening and nodule formation of the conjunctiva
near the limbus with confluence of the nodules. The white
lesiions on top of the nodules are Horner-Trantas dots
consisting of desquamated epithelial cells.
 It is having collections of Eosinophils at Limbus in Vernal
Conjunctivitis.
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KAYES' DOT
 Kaye dots are white punctate epithelial opacities located in the
epithelium anterior to the suture line of a corneal graft.
 The dots represent epithelial cells in various stages of
degeneration on histopathology and it has been hypothesized that
they may result from an epithelial response to the area of tissue
angulation.

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MITTENDORF'S DOT
 A Mittendorf dot is a small, circular opacity on the posterior lens capsule,
classically nasal in location, which represents the anterior attachment of
the hyaloid artery.
 The hyaloid artery is present during gestation and typically regresses
completely.
 Failure to do so can lead to benign findings, such as a Mittendorf dot or a
Bergmeister's papilla, or pathologic changes as seen in persistent fetal
vasculature syndrome.
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ARLT'S LINE
 Arlt's line is a thick band of scar tissue in
the conjunctiva of the eye, near the lid margin, that is
associated with eye infections.
 Arlt's line is a characteristic finding of trachoma, an
infection of the eye caused by Chlamydia trachomatis.
 The line runs horizontally, parallel to eyelid, and is found
at the junction of the anterior one third and posterior two
thirds of the conjunctiva.
 The line is named after the Austrian ophthalmologist Carl
Ferdinand von Arlt.
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EHRLICH-TURCK LINE
 Linear deposition of KPs in uveitis
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FERRY'S LINE
 Seen in front of filtering bleb in glaucoma.
 Filtering bleb is a blister of conjunctiva resulting from
glaucoma surgery by which a flap of sclera is created in
the eye wall, allowing aqueous humor to percolate out of
the eye and underneath the conjunctiva, thus lowering
intraocular pressure.
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HUDSON-STAHLI LINE
 The Hudson–Stahli line is a line of iron deposition lying
roughly on the border between the middle and lower thirds
of the cornea.
 It lies in the corneal epithelium. Usually it has about
0.5 mm in thickness and is 1–2 mm long.
 It is generally horizontal, with possible mild downward
trend in the middle.
 It is present normally in people over the age of 50, but
seems to dissipate to some degree by the age of 70.
 The Hudson-Stahli line is not associated with any pathology
calling for clinical intervention. Formation of the line may
depend upon the rate of tear secretion.
 However, the Hudson-Stahli line can be enhanced
in hydroxychloroquine toxicity.
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HUDSON-STAHLI LINE
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KHODADOUST LINE
 A Khodadoust Line or chronic focal transplant reaction is
a medical sign that indicates a complication of corneal
graft surgery on the eye.
 This method is called Khodadoust Line because of many years
research about this by Professor Ali Asghar Khodadoust.
 This medical condition is similar to organ rejection after
an organ transplant, except that it involves immunological
rejection of a transplanted cornea rather than an internal organ.
 A Khodadoust line is made up of mononuclear cells (white
blood cells). These cells appear at the vascularized edge of the
recently transplanted cornea.
 If untreated, the line of white blood cells will move across and
damage the endothelial cells of the cornea over the space of
several days.
 Prompt treatment by immunosuppression can prevent further
damage
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KHODADOUST LINE
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PATON'S LINE
 Circumferential retinal folds in peripapillary region due to
papilledema.
 Papilledema is defined as optic nerve head edema
secondary to increased intracranial pressure. The main
cause of optic nerve head swelling is blockage of the
axoplasma transport and the blockage occurs at the
lamina cribrosa.
 The optic nerve head can swell to the extent where it is
extended forward into the vitreous as well as laterally.
 This lateral swelling causes the retina to buckle inward at
the temporal aspect of the optic nerve head. The buckling
is known as Paton's lines or folds.
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SAMPAOLESI LINE
 Sampaolesi line is a sign which may be observed during
a clinical eye examination.
 During gonioscopy (where the structures of the
eye's anterior segment are examined), if an abundance
of brown pigment is seen at or anterior to Schwalbe's
line, a Sampaolesi line is said to be present
 The presence of a Sampaolesi line can signify pigment
dispersion syndrome or pseudoexfoliation syndrome,
trauma and iris melanoma.
 Gonioscopy is performed during eye examinations, which
involves placing a mirrored lens on the patient's cornea in
order to visualise the angle of the Anterior chamber of
eyeball.
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SAMPAOLESI LINE
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SCHEIE'S LINE OR ZENTMAYER'S LINE
 Pigment on lens equator and posterior capsule in pigment
dispersion syndrome.
 Peripheral pigmentation of the posterior lens capsule
anterior to the junction between the anterior hyaloid face
and the posterior lens capsule (ligamentum hyaloideo-
capsulare of Wieger)
 "Scheie's line" is considered to be pathognomonic for
pigment dispersion syndrome.
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SCHEIE'S LINE OR ZENTMAYER'S LINE
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SCHWALBE'S LINE
 Schwalbe's line is the anatomical line found on the interior
surface of the eye's cornea, and delineates the outer limit of
the corneal endothelium layer.
 Specifically, it represents the termination of Descemet's
membrane.In many cases it can be seen via gonioscopy.
 Some evidence suggests that the corneal endothelium
actually possesses stem cells that can produce endothelial
cells, especially after injury, albeit on a limited scale.
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STOCKERS LINE
 A vertical line at the head of pterygium has been termed
Stocker's line.
 The lesion consisted of corneal linear iron deposition.
 Stocker's line is a punctate, brownish, subepithelial line
passing vertically in front of the invasive apex of the
pterygium.
 The mechanism of iron deposition in the development of
pterygium is still unknown, but iron level was reported
significantly higher in the pterygium tissue than in the normal
conjunctiva
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STOCKERS LINE
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WHITE LINES OF VOGT
 Sheathed or sclerosed vessels seen in Lattice degeneration.
 Lattice degeneration of the retina is a fairly common
degenerative disease of the peripheral retina characterized by
the presence of lattice lines created by fibrosed blood vessels.
 Crisscrossing fine white lines that account for the name lattice
degeneration are present in roughly only 10% of lesions and
most likely represent hyalinized blood vessels.
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FINGERPRINT LINE
 Corneal map-dot-fingerprint dystrophy is by far the most common
corneal dystrophy and is named for the appearance of its
characteristic slit-lamp findings.
 Map-dot-fingerprint dystrophy is also known as epithelial basement
membrane dystrophy, anterior basement membrane dystrophy, and
Cogan microcystic epithelial dystrophy.
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KRUKENBERG SPINDLE
 Krukenberg's spindle is the name given to the pattern
formed on the inner surface of the cornea by
pigmented iris cells which are deposited as a result of the
currents of the aqueous humor.
 The sign was described in 1899 by Friedrich Ernst
Krukenberg(1871-1946), who was a
German pathologist specialising in Ophthalmology
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VOGT STRIAE
 Vogt's striae are vertical (rarely horizontal) fine, whitish
lines in the deep/posterior stroma and Descemet's
membrane commonly found in patients with keratoconus.
 It may be asymmetric depending on the degree of
keratoconus in each eye. There is a positive correlation
between the orientation of the lines with the steepest axis
of the cornea and the mechanism is thought to be related
to mechanical stress forces on collagen lamellae
radiating from the cone apex.
 The striae can temporarily disappear with external
pressure to the globe.
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HAAB’S TRIAE
 Haab's striae, or Descemet's tears, are horizontal
breaks in the Descemet membrane associated
with congenital glaucoma.
 It is named after Otto Haab.
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RING KERATITIS
 Acanthamoeba keratitis, first recognized in 1973, is a rare, vision
threatening, parasitic infection seen most often in contact lens
wearers.
 It is often characterized by pain out of proportion to findings and
the late clinical appearance of a stromal ring shaped infiltrate.
 It is both difficult to diagnose and difficult to treat.
 If clinical suspicion exists, the involved area of cornea can be
scraped with a sterile instrument (blade, spatula, needle, calcium
alginate swab, or cotton tip applicator) under topical anesthesia at
the slit lamp.
 The culture specimen can then be inoculated into a dish of E. coli
plated over non-nutrient agar.
 Acanthamoeba trophozoites and cysts can also be identified with
the help of Gram, Giemsa-Wright, hematoxylin and eosin, periodic
acid-Schiff, calcoflour white, or other stains.
 Confocal microscopy has also been used to diagnose
Acanthamoeba cysts with some success.
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RING KERATITIS
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KAYSER–FLEISCHER RINGS
 Kayser–Fleischer rings (KF rings) are dark rings that
appear to encircle the iris of the eye.
 They are due to copper deposition in part of
the cornea (Descemet's membrane) as a result of
particular liver diseases.
 They are named after Dr. Bernhard Kayserand Dr. Bruno
Fleischer, the German doctors who first described them in
1902 and 1903. Initially thought to be due to the
accumulation of silver, they were first demonstrated to
contain copper in 1934.
 The rings, which consist of copper deposits where
the cornea meets the sclera, in Descemet's membrane,
first appear as a crescent at the top of the cornea.
Eventually, a second crescent forms below, at 6 o'clock,
and ultimately completely encircles the cornea
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KAYSER–FLEISCHER RINGS
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CORNEAL RUST RING
 Corneal rust rings occur commonly when metallic foreign
bodies become embedded in the cornea.
 Removal of the rust ring is imperative to avoid permanent
staining of the cornea, persistent inflammation, or
disruption of corneal integrity (necrosis) with loss of
stromal substance.
 Two techniques for the removal of rust rings are
discussed: hypodermic needle extraction and corneal burr
drill removal.
 The use of topical deferoxamine as a chemical chelator
should only be used by an Ophthalmologist and is
mentioned only for the sake of completeness.
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CORNEAL RUST RING
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COAT’S WHITE RING
 GEORGE COATS was the first to describe two cases
‘showing a small superficial opaque white ring in the
cornea.’(Stromal discrete). Size usually 0.1 to 0.2mm in
diameter.
 The rings were round, oval and pear-shaped; the majority
were situated in the periphery of the cornea, but a few
were present -near its centre.
 It is a form of iron deposit at the level of Bowman’s layer
due to metallic foreign body.
 It also may be associated with previous corneal foreign
body and mostly occurs after focal corneal injury
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COAT’S WHITE RING
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FLEISCHER RING
 Fleischer rings are pigmented rings in the peripheral cornea,
resulting from iron deposition in basal epithelial cells, in the
form of hemosiderin.
 They are usually yellowish to dark-brown, and may be
complete or broken.
 They are named for Bruno Fleischer.
 Fleischer rings are indicative of keratoconus, a degenerative
corneal condition that causes the cornea to thin and change to
a conic shape.
 Some confusion exists between Fleischer rings and Kayser-
Fleischer rings.
 Kayser-Fleischer rings are caused by copper deposits, and
are indicative of Wilson's disease, whereas Fleischer rings are
caused by iron deposits.
 One example of a medical condition that can present with
Fleischer rings is Keratoconus.
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FLEISCHER RING
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SOEMMERING RING
 SomEm RiNG's ring is a special form of after-cataract which is
formed in the following ways:
 In extra-capsular extraction of cataract in which the central
portion of the anterior capsule is removed, or in injury of the
lens, or in discission operations in which the anterior capsule is
torn and the central portion of the lens substance is penetrated
and becomes absorbed, a greater part of the capsule sac
remains intact.
 According to Wessely (1910), when the central part of the
anterior capsule is opened up, it then loses its stretching
capacity and collapses, forming at first a flat ring.
 The torn anterior capsule then becomes retracted and adheres
to the posterior capsule at the margin, so that the remains of
the lens fibres cannot be absorbed and therefore form a ring of
folded capsule.
 The epithelial cells can grow in this ring and, associated with
the deposition of hyaline capsular material in the remains of the
lens substance, a swollen ring or cushion is formed.
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SOEMMERING RING
 In its typical form, Soemmering's ring can only be
diagnosed clinically after its dislocation has taken place,
when a coloboma of the irs has been made, or when the
pupil has been widely dilated.
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VOSSIUS RING
 A Vossius ring is a well-circumscribed complete or incomplete
ring of pigment deposited on the anterior lens capsule surface,
usually as a result of significant blunt eye trauma.
 The disease was first described by Vossius in 1903, at which
time he discussed both a pigmented variety of ring and a non-
pigmented variety that he thought was a result of degeneration
of anterior lens epithelial cells.
 The non-pigmented form is no longer considered to be a
Vossius ring.
 When the eye is injured, a circular ring of fainted or
stippled opacity is seen on the anterior surface of the lens due
to brown amorphous granules of pigment lying on the capsule.
 It has the same diameter as the contracted pupil, and is due to
impression of the iris on the lens as a result of the force of
a concussion injury, which drives the cornea and iris backward.
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WEISS RING
 A Weiss ring is a type of 'floater'.
 These are pieces of debris that float around in the vitreous
humor of the eye, which is the gel-like substance that sits
inside the eyeball - between the lens and the retina. Floaters
are often caused by shrinkage of the vitreous humor, causing
tiny specks of collagen-like material to become visible as
floating spots or threads in your field of vision.
 This is more common as you get older and is most noticeable
when moving your eyes across a light background.
 A Weiss ring is a much larger, ring-shaped floater that is
created by a posterior vitreous detachment (PVD) from around
the optic nerve head. In other words, this is when the vitreous
tissue detaches from the retina.
 One (most common) or multiple large floaters that are circular,
ovoid or shaped in a bent line
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WEISS RING
 While a Weiss ring is usually harmless and will disappear
on its own eventually, in a small number of cases a PVD
can cause a retinal tear.

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DOUBLE RING SIGN
 In optic nerve hypoplasia, optic disc is often pale or gray
and smaller than normal.
 Optic discs often present with double ring sign – yellow to
white ring around the disc. A ring of hypopigmentation or
hyperpigmentation often, but not always surrounds the
disc defining the area of the putative scleral canal.
 The outer ring represents the normal junction between
sclera and the lamina cribrosa; the inner ring represents
the abnormal extension of retina and pigment epithelium
over the outer portion of the lamina cribrosa.
 Tortuous retinal arterioles, venules, or both may
accompany ONH, but retinal vessels can also present
with normal caliber.
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DOUBLE RING SIGN
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GOLDEN RING
 A golden ring within the lens is evidence of a good,
successful hydro delineation during cataract surgery.
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Dots spots lines and rings in ophthalmology

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