Cotton Wool Patches in Neuro-op

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Identifier Cotton_Wool_Patches_in_Neuroop
Title Cotton Wool Patches in Neuro-op
Creator Andrew G. Lee, MD; Stephanie Xiong
Affiliation (AGL) Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, Texas; Professor of Ophthalmology, Weill Cornell Medicine, New York City, New York; (SX) Class of 2023, Baylor College of Medicine, Houston, Texas
Subject Cotton Wool Patches; Neuro-Ophthalmology; Medical Condition
Description Dr. Lee lectures medical students on cotton wool patches in neuro-ophthalmology.
Transcript So today we're going to be talking about cotton wool patches in neuro-ophthalmology, and I'm not going to be focusing on the retina things except to just let you know they're in the differential diagnosis. I prefer what Dr. McLeod calls the cotton wool "sentinel", and the reason I like that word "sentinel" as opposed to "patch" is the "sentinel" tells us that there's something systemically wrong with any patient who has a cotton wool patch. So a cotton wool patch is really a sentinel of systemic disorder. And the common ones are of course the retinal etiologies for the cotton wool patch, and I'll just cover them so the differential is complete. Of course, diabetic retinopathy, hypertensive retinopathy; these are the super common causes of cotton wool patches. And then vascular occlusive disease: Either branch or central retinal artery occlusion. Or branch or central retinal vein occlusion. And so when we're looking at cotton wool patches as a sentinel of systemic vascular disease, one of the things that's going to be interesting is both the shape, the morphology, and the pattern of the cotton wool spots. And these help us determine whether we're dealing with the common causes or whether we're dealing with uncommon causes. And the uncommon causes include radiation retinopathy, which can look just like diabetic retinopathy; or if we have a hematologic problem like leukemia and infiltration of the retina as a result of leukemia; or if we have some type of vasculitis, it's an arteritis and the vasculitis is what's causing the problem; or if we have something in the blood itself that is causing it to make a small vessel microangiopathy leading to the nerve fiber layer infarction which we see as the cotton wool spot. And that can be cryoglobulins or it can be other paraproteins in your blood; things that cause a small vessel occlusive thing. And then we've got emboli either from the carotid or from the aorta. So microemboli can cause microinfarcts in the nerve fiber layer. Especially if it's bilateral, we should be thinking about aorta in that setting. And so these are the uncommon causes of cotton wool patches. And we should worry about HIV. So these are the main neuro-op things that we have to worry about once we've excluded the common retinal things. And so for me, looking at cotton wool patches is kind of like looking at clouds. So when we're; looking at clouds, they're like cotton wool patches. So they're kind of fluffy and white. And so it depends what level we are. So for at the lowest levels, the clouds can be horizontal like a stratum. So these are stratus clouds which are in the stratified horizontal, and that; corresponds to the types of cotton wool patches we see in arterial occlusions and in vein occlusions where the cotton wool patches are lining up along the artery or the vein. Versus cumulus clouds which are accumulating so they're big and fluffy. And if you get; into the middle layer you'll have the altostratus and altocumulus, but we don't have an equivalent for that in the eye. And then we have at the top, cirrus clouds. But what we do have as an equivalent analogy in clouds is if there's dark color in the cloud. And in the cloudworld that's called Nimbus. So Nimbus is a dark cloud. And a dark cloud is a; sentinel of dark things. And so in the eye what we're looking for is hemorrhage. So the hemorrhage is kind of our Nimbus equivalent. ; So if we see cotton wool patches that are along an artery, they're cumulative and it's white, that's going to be the distinctive finding for the branch retinal artery occlusion. If however, we have a cherry red spot and the cumulus is the entire fundus, and it's opaque and white, that's going to be the finding for central retinal artery occlusion. And at the border zone between the ischemic area and the non-ischemic area, that ischemic penumbra can make the cotton wool patch. In vein occlusions, we're going to see Nimbus, which is the hemorrhage. The vein is leaking out the blood products, and so again, it'll be along the vein but there will be hemorrhages, flame hemorrhages along the vein in the branch retinal vein occlusion or diffusely in the central retinal vein occlusion. So the hemorrhage along the vein, cotton-wool patches, that's vein occlusion. In diabetes and hypertension, the vessels that are affected are much smaller than the large vessels. And so the cotton wool patches tend to occur in between the vein and the artery. And the hemorrhages, as opposed to being superficial and inflamed, are dot and blot hemorrhages in diabetes. So it kind of is defined by the company it keeps. And the leakage can produce macular exudate. And so those features are the features that make it the common things. Diabetic retinopathy, hypertensive retinopathy, branch retinal vein occlusion, central retinal vein occlusion, and arterial occlusions. In contrast, radiation therapy looks like diabetic retinopathy, but they've had a history of radiation to the head or neck. Leukemic is going to have the nimbus, which is the hemorrhages. And sometimes those hemorrhages are white spot inside the red that's a roth spot. In vasculitis, we'll have leakage on the fluorescein angiogram. And that can include giant cell arteritis. So an elderly patient that has multifocal cotton wool patches, we should be thinking about giant cell arteritis, the vasculitis of the elderly. If it's a hypercoagulable problem, we'll see the little cotton wool patches and things like cryoglobulins and other problems with the viscosity in the blood can produce the multifocal cotton wool patches. But they're not in this typical distribution for a typical vein or arterial occlusion. They're in between the artery and the vein. And same thing with the emboli. With our small microemboli into the smaller vessels producing cotton wool patches, but in between the artery and the vein. And HIV also looks like that. In addition, we can have a picture that looks like multifocal cotton wool patches with or without some hemorrhages in Purtscher retinopathy (Purtscher) or a Purtscher-like retinopathy. And those are also cotton wool patches that are in between the small microemboli, whether that's microemboli from pancreatitis, or an abdominal source, or from chest compressions. Or Purtscher-like retinopathy in patients that have the hematologic problems. So neuro-op, make sure the cotton wool patches in the common things: diabetes, hypertension, arterial or vein occlusion. If it's not in the common patterns, think about the uncommon conditions: radiation, hematologic problems, vasculitis, HIV, Purtscher and Purtscher-like retinopathy, and microemboli from an aortic or carotid source.
Language eng
Format video/mp4
Type Image/MovingImage
Collection Neuro-Ophthalmology Virtual Education Library: Andrew G. Lee Collection: https://novel.utah.edu/Lee/
Publisher North American Neuro-Ophthalmology Society
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E SLC, UT 84112-5890
Rights Management Copyright 2019. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
ARK ark:/87278/s68d5fk1
Setname ehsl_novel_lee
ID 1578874
Reference URL https://collections.lib.utah.edu/ark:/87278/s68d5fk1
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