Roth Spots: NBEO and OKAP Exam Guide

Master Roth spots for NBEO and OKAP: causes, differential diagnosis, and the classic exam trap eye care students must know.

Reviewed for accuracyJuly 27, 20263 min read

Side-by-side fundus photo comparison of a Roth spot, a white center surrounded by a hemorrhagic red halo, and a cotton wool spot, a pure white fluffy infarct with no surrounding hemorrhage, illustrating the key distinguishing feature between the two white-centered retinal lesions

Warm-up

What most commonly composes the white center of a Roth spot?

Lesson

Roth Spots in 30 Seconds

Roth spots are white-centered retinal hemorrhages, typically located in the nerve fiber layer, classically linked to infective endocarditis (subacute bacterial endocarditis), though the differential is much broader on exam. Recognizing the white-centered pattern and knowing the systemic workup direction is the high-yield skill for NBEO and OKAP.

What Causes a Roth Spot

A Roth spot forms when a superficial retinal capillary ruptures and bleeds into the nerve fiber layer. The white center most commonly represents fibrin-platelet aggregates, although inflammatory cells, infectious material, ischemic retinal tissue, or leukemic cells may contribute depending on the underlying disease.

The Differential Diagnosis

Infective endocarditis (classically subacute bacterial endocarditis): the classic board association, caused by retinal vascular injury related to the underlying infection.
Leukemia: white-centered retinal hemorrhages may occur because of anemia, thrombocytopenia, leukostasis, and leukemic retinal infiltration.
Severe anemia: any cause of profound anemia can produce Roth spots through capillary fragility and impaired oxygen delivery.
Diabetic retinopathy: white-centered hemorrhages can appear in severe nonproliferative or proliferative disease and are a frequent exam distractor.
HIV retinopathy: white-centered retinal hemorrhages may occur as part of HIV retinopathy.
Purtscher retinopathy: trauma-associated white-centered hemorrhages and cotton wool spots from microvascular occlusion after severe compressive injury.
Abusive head trauma (formerly shaken baby syndrome): multilayered retinal hemorrhages in a pediatric patient with no accidental trauma history should raise immediate concern for abuse.

4 Facts Exams Always Ask

Although infective endocarditis is the classic board association, leukemia, anemia, diabetic retinopathy, and other systemic disorders are also well recognized causes.
A single identified cause does not end the workup. Multiple contributing pathologies can coexist and exams test whether you keep looking.
The systemic workup, guided by the history and physical examination, includes CBC with differential, blood cultures when infection is suspected, and echocardiography if endocarditis is on the differential.
Roth spots are distinguished from cotton wool spots by the presence of an actual hemorrhagic component surrounding the pale center, while cotton wool spots are pure nerve fiber layer infarcts without hemorrhage.

The Classic Trap

A common board pitfall is assuming Roth spots are pathognomonic for infective endocarditis. Exam writers frequently place a Roth spot in a vignette with anemia, leukemia, or diabetic retinopathy findings to test whether the student anchors on endocarditis reflexively. The correct reasoning is to treat the Roth spot as a nonspecific sign that demands a broad systemic workup, not a single-diagnosis shortcut.

Clinical Pearl

A CBC is an appropriate early investigation because it may identify anemia or leukemia, but the presence of a new murmur or other features suggestive of infective endocarditis should prompt urgent blood cultures and echocardiography as well. Roth spots are a clinical sign rather than a diagnosis, and treatment is always directed at the underlying systemic disease.

Check yourself

Checkpoint 1

A Roth spot is identified on dilated exam. Which statement about its differential diagnosis is most accurate?

Checkpoint 2

How are Roth spots distinguished from cotton wool spots on fundus exam?

Clinical case

A 34-year-old presents with fatigue, easy bruising, and a white-centered retinal hemorrhage on dilated exam. No fever, no murmur, no history of trauma. Vital signs are normal. What is the most appropriate next diagnostic step, and which systemic disease is most strongly suggested by this presentation?

What is the most appropriate next diagnostic step?

Explanation

The absence of fever, cardiac findings, or infectious symptoms shifts the differential toward a hematologic disorder such as leukemia or severe anemia. A CBC with differential is the appropriate next investigation, guided by the history and exam rather than reflexively pursuing an endocarditis workup.

Case discussion

The absence of fever, cardiac findings, or infectious symptoms shifts the differential toward a hematologic disorder such as leukemia or severe anemia. A CBC with differential is therefore the appropriate next investigation. This case tests whether the student avoids anchoring on the classic endocarditis association when the history points elsewhere.

Sources & Reviewer Info

Reviewed by Vasilis Inglezis: Optometrist and Ocular Oncology Imaging Specialist, Ocular Oncology Center, Athens, Greece. Last updated July 27, 2026.

Diagram created with AI image generation, clinically reviewed for accuracy.

References

AAO EyeWiki, Roth Spots
AAO BCSC Section 12, Retina and Vitreous
Ryan's Retina
Wills Eye Manual

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