199:
forms of multiple sclerosis, after four years of using fingolimod (also known by its brand name
Gilenya), another drug used to treat relapsing forms of multiple sclerosis, she was switched to cladribine. On day five of her second cycle of cladribine, she reported a shadow in her right eye, of which on day seven during an eye exam a cotton wool spot was found in the same eye. Six weeks after completing the second cycle of cladribine, the reported cotton wool spot was still present albeit reduced in size. At the 12-week mark, her vision returned to normal and the cotton wool spot was undetectable after 10 months. The study postulates the possibility that cladribine use may cause cotton wool spots due to its side effects of lymphopenia, neutropenia, thrombocytopenia, pancytopenia, and infections as well as the timing of the formation of cotton wool spots in line with cladribine use in a person who otherwise had no risk factors for cotton wool spots as well as the resolution of cotton wool spots once off cladribine for an extended period of time.
242:
wool spots appear much smaller in HIV/AIDS in comparison to the cotton wool spots that appear in diabetes. Although, the difference in duration or half-life of the cotton wool spots may be a result of differing demographics that are affected by the underlying diseases and the overall health of the retinal vessels affected. In addition, it is thought that age may play a factor for the duration of cotton wool spots in diabetic patients. In one study, cotton wool spots were found to have a shorter duration in diabetic patients under forty years old compared to the cotton wool spots in diabetic patients over forty years old. Although there is no direct treatment of cotton wool spots, targeting the underlying origin of the disease can be beneficial in treating the cotton wool spots.
124:
208:
indicators of being immunocompromised, and having blood pressures under 140/90 mm Hg (no chronic hypertension), presented with cotton wool spots in one of their eyes. Since no other risk factors were present and the common factor between the four subjects was chronic migraines, the study postulates that vasospastic syndromes common in those with chronic migraines may lead to ischemia in the eyes leading to the formation of cotton wool spots, as cotton wool spots can also act as an indicator of general vasospastic activity.
20:
151:(GCA), a type of inflammation of the lining of the arteries, as this may reduce blood flow to the eyes. In a study of 123 subjects with vision loss due to early stage giant cell arteritis, one-third of subjects had cotton wool spots present in their eyes. Furthermore, because giant cell arteritis can lead to loss of vision and is associated with cotton wool spots, it is recommended to investigate for giant cell arteritis if cotton wool spots are found.
225:
include a complete blood count, basic metabolic panel, digestive enzymes such as amylase and lipase, and even several blood pressure measurements. Another method of diagnosis or screening is through the use of spectral domain optical coherence tomography (SD-OCT) which follows the cotton wool spots and their progression. The emergence of advanced technological tools like SD-OCT are providing new insight of neurosensory retinal health
71:. These associated findings are common due to the underlying diseases causing these manifestations seen in the eyes. Because of the use of cotton wool spots more as an indicator of other systemic diseases, Mcleod had proposed that the taxonomy of the terms 'cotton wool spot' should be changed to something else to help better understand its true meaning.
80:
to these nerves may result from organelle accumulation in the axons. This is further purported by the presence of cytoid bodies in ganglion axon cells, where the accumulation of white blood cells, more specifically, eosinophils, mitochondria, and other cellular material lead to swelling of the ganglion axon cells which then lead to cotton wool spots.
67:
that when present, frequently act as a significant indicator, or sign, of a variety of underlying disease states. These fluffy white spots are often accompanied by additional abnormal funduscopic findings such as intraretinal bleeds, hard exudates, and atypical small blood vessels, including obstructed or dilated blood vessels and
250:
is performed to determine lasting damage to the obstructed retinal capillaries. The severity of the cotton wool spots is the major determining factor in the extent of lasting capillary damage. Following the resolution of cotton wool spots, visual function does not typically recover, although cases of
241:
Currently there are no direct treatments for cotton wool spots, however, they may fade away or disappear completely on their own in about 6 to 12 weeks. The duration of cotton wool spots typically depends on the underlying disease state that caused the cotton wool spots to appear. For example, cotton
198:
and antineoplastic drug used to reduce relapse rates and slow down disease progression for people with relapsing forms of multiple sclerosis in those who have not benefitted from or were unable to use other drugs multiple sclerosis. In a case study of a 39-year-old female with a history of relapsing
79:
Cotton wool spots are commonly caused by changes to the retina secondary to diabetes, hypertension, or blockages to blood vessels to the retina, such as central retinal vein occlusion. While at one point believed to have been the result of nerve damage in the retina, interruptions to axoplasmic flow
66:
Cotton wool spots present as opaque fluffy white spots, sometimes with feather-like edges, on the retina when seen on a funduscopic exam. These opaque white areas are typically asymptomatic, but may cause some vision loss due to the underlying disease state. Cotton wool spots are a retinal condition
224:
To ensure proper etiology and diagnosis, those presenting with symptoms would require a thorough history and eye exam which includes dilated retinal evaluation. Depending on the findings, a person may require further workup including blood tests to explore other potential causes. The blood work may
220:
Cotton wool spots have two different types of ways to differentiate between other disease states or conditions that contribute to the same outcomes. One of the ways, takes account for all the conditions that are present in the eye that may actually look like cotton wool spots. The second way takes
143:
can also lead to the appearance of cotton wool spots. Although they are associated with multiple systemic diseases, it is possible for there to be an unknown etiology that would require further investigation. Cotton wool spots have different clinical characteristics when present as a result of HIV
207:
Another proposed associated cause of cotton wool spots is chronic migraines. In a study of four subjects, two male and two female, with chronic migraines and no other present risk factors for cotton wool spots, such as normal hemoglobin A1C and blood glucose (indicating no diabetic risk), no
57:
The presence of cotton wool spots may resolve independently over time, typically in 4–12 weeks, or may depend on the underlying disease causing the condition. Diagnosis and treatment of the underlying disease state may be beneficial in the treatment and management of cotton wool spots.
211:
As there are many causes of cotton wool spots, oftentimes ophthalmologists will convey the findings to the person's primary health care provider and emphasize that the appearance of cotton wool spots may need workup to investigate the root cause and proper treatment pathway.
50:, which is located in the distribution of the capillaries of the superficial layer of the retina. These areas with reduced blood flow reflect the obstruction of axoplasmic flow due to mechanical or vascular causes and the consequential accumulation as a result of decreased
232:
However, funduscopic exams that find patchy opaque areas on the retina may misdiagnose the condition as cotton wool spots instead of transient branch retinal artery occlusion (BRAO) which also does not effect vision and self-resolves.
251:
recovery have been documented. The exact mechanics of visual recovery is mostly unknown, but may be associated with the survival of enough ganglion axon cells to meet a necessary threshold for vision to successfully recover.
120:, referring to the increase in white blood cells as a probable cause. Although cotton wool spots are a secondary manifestation to leukemia, they have been found to be a poor prognostic sign for survival in acute leukemia.
245:
While in the acute phase, the fluorescent funduscopy exam shows obstruction of retinal capillaries in the area of the cotton wool spots. Once these areas of opacity resolve and the retina evaluation returns to normal, a
1141:
Mansour AM, Jampol LM, Logani S, Read J, Henderly D (August 1988). "Cotton-wool spots in acquired immunodeficiency syndrome compared with diabetes mellitus, systemic hypertension, and central retinal vein occlusion".
138:
More recently, prolonged travel in space has been found to be a probable cause of cotton wool spots in people who experience ocular changes after coming back from space. Although infrequent, conditions like HIV and
1222:"The Wills Eye Manual Office and Emergency Room Diagnosis and Treatment of Eye Disease Fifth Edition Eds: Justis P. Ehlers and Chirag P. Shah 2008 ISBN: 978-0-7817-6962-4 Lippincott Williams & Wilkins"
194:
While still an ongoing and recent investigation, cladribine use can also be associated with the development of cotton wool spots. Cladribine, also known by its brand name
Mavenclad, is a purine
735:
Yassin MA, Ata F, Mohamed SF, Alkhateeb A, Naeem U, Al-Qatami AI, et al. (2022). "Ophthalmologic manifestations as the initial presentation of chronic myeloid leukemia: A review".
1124:
144:
rather than in systemic diseases, like diabetes or hypertension, due to the viral complexes that cause structural changes to the retinal microvasculature.
54:. This reduced axonal transport can then cause swelling or bulging on the surface layer of the retina, increasing the potential for nerve fiber damage.
1100:
711:
531:
123:
301:"Isolated cotton-wool spots of unknown etiology: management and sequential spectral domain optical coherence tomography documentation"
38:
exam (also called an ophthalmoscopic exam). Cotton wool spots are typically a sign of another disease state, most common of which is
88:
Referred to as a form of retinal myopathies, cotton wools spots are commonly found to be a secondary manifestation to diseases like
1005:
Gummi R, Walsh RD, Ahmad B (February 2021). "Retinal cotton wool spot associated with cladribine therapy for multiple sclerosis".
104:, a condition caused by damaged blood vessels in the retina due to high blood sugar. Abundant cotton wool spots are also found in
174:
178:
170:
155:
130:
occurs when long standing diabetes begins to damage blood vessels in the eyes which leads to leakages in the eyes, known as
23:
An ophthalmoscopic view of the retina showing advanced signs of diabetic retinopathy including two pale cotton wool spots.
1177:
Mansour AM, Rodenko G, Dutt R (March 1990). "Half-life of cotton-wool spots in the acquired immunodeficiency syndrome".
778:
Abu el-Asrar AM, al-Momen AK, Kangave D, Harakati MS (1996). "Prognostic importance of retinopathy in acute leukemia".
140:
962:
Khan MA, Ho AC, Spirn MJ (2017). "Cotton-Wool Spots After Use of
Macitentan for Pulmonary Arterial Hypertension".
47:
105:
116:, or a sudden occlusion of the arteriole. One study observed the presence of cotton wool spots in people with
247:
19:
1275:
109:
177:, can be bilateral cotton wool spots. As such, if a person develops cotton wool spots after starting an
260:
148:
127:
101:
39:
1251:
1202:
1118:
1030:
987:
895:
803:
760:
162:
915:"Clinical and pathological correlation of cotton wool spots in secondary angle closure glaucoma"
870:
Khossravi EA, Hargens AR (January 2021). "Visual disturbances during prolonged space missions".
1243:
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402:
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649:
608:
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519:
448:
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392:
384:
322:
312:
51:
229:, especially in cases such as analysis of the retina post-resolution of cotton wool spots.
1155:
939:
914:
847:
822:
662:
637:
613:
588:
523:
453:
428:
397:
372:
327:
300:
195:
117:
35:
1092:
The Wills eye manual: office and emergency room diagnosis and treatment of eye disease
748:
1269:
1034:
899:
764:
388:
1255:
1206:
991:
589:"Why cotton wool spots should not be regarded as retinal nerve fibre layer infarcts"
807:
478:"The mystery of cotton-wool spots - a review of recent and historical descriptions"
93:
975:
883:
547:
Hendrick AM, Gibson MV, Kulshreshtha A (September 2015). "Diabetic
Retinopathy".
444:
1018:
131:
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560:
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113:
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406:
336:
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799:
701:
97:
89:
68:
43:
823:"A review on automatic analysis techniques for color fundus photographs"
653:
317:
791:
226:
165:
in
Pennsylvania found that a potential side effect of medications like
429:"Imaging of long-term retinal damage after resolved cotton wool spots"
158:
as a result of reduced blood flow from retinal arteriole obstruction.
31:
181:, medication side effect should be considered as a plausible cause.
134:
and the appearance of yellow-white spots known as cotton wool spots.
1054:
Canadian
Journal of Ophthalmology. Journal Canadien d'Ophtalmologie
122:
18:
689:(2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
636:
Terelak-Borys B, Skonieczna K, Grabska-Liberek I (August 2012).
221:
account for the root cause or causes of the cotton wool spots.
1226:
Graefe's
Archive for Clinical and Experimental Ophthalmology
427:
Gomez ML, Mojana F, Bartsch DU, Freeman WR (December 2009).
299:
Ioannides A, Georgakarakos ND, Elaroud I, Andreou P (2011).
34:
of the eye that are considered an abnormal finding during a
514:
154:
Another condition in which cotton wool spots are found is
112:, where the white patches are a result of a microvascular
100:. Cotton wool spots have become one of the hallmarks of
42:. The irregularly shaped white patches are a result of
913:
Bhatt A, Nguyen C, Mosaed S, Minckler D (June 2018).
780:
827:Computational and Structural Biotechnology Journal
638:"Ocular ischemic syndrome - a systematic review"
294:
292:
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282:
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278:
276:
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919:American Journal of Ophthalmology Case Reports
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420:
418:
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366:
1050:"Cotton-wool spots in patients with migraine"
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364:
362:
360:
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352:
350:
348:
346:
8:
509:
507:
505:
503:
373:"Acute retinal arterial occlusive disorders"
147:Cotton wool spots are also associated with
46:, or reduced blood flow and oxygen, in the
1123:: CS1 maint: location missing publisher (
700:Yanoff M, Duker JS, Augsburger JJ (2009).
1237:
1065:
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452:
396:
326:
316:
1007:Multiple Sclerosis and Related Disorders
1179:International Journal of STD & AIDS
272:
30:are opaque fluffy white patches on the
1116:
102:pre-proliferative diabetic retinopathy
7:
1156:10.1001/archopht.1988.01060140230030
821:Besenczi R, Tóth J, Hajdu A (2016).
593:The British Journal of Ophthalmology
482:European Journal of Medical Research
377:Progress in Retinal and Eye Research
1048:Yuan PH, Micieli JA (August 2022).
1095:(7th ed.). Philadelphia, PA.
706:(3rd ed.). : Mosby Elsevier.
524:10.1016/b978-1-4557-0737-9.00051-5
14:
964:Retinal Cases & Brief Reports
749:10.1016/j.survophthal.2021.07.001
872:Current Opinion in Ophthalmology
389:10.1016/j.preteyeres.2011.05.001
687:Eye pathology an atlas and text
175:pulmonary arterial hypertension
179:endothelin receptor antagonist
171:endothelin receptor antagonist
156:central retinal vein occlusion
1:
976:10.1097/ICB.0000000000000273
884:10.1097/ICU.0000000000000724
445:10.1016/j.ophtha.2009.05.012
371:Hayreh SS (September 2011).
16:Medical condition of the eye
1019:10.1016/j.msard.2020.102661
1292:
1191:10.1177/095646249000100213
1067:10.1016/j.jcjo.2021.11.006
931:10.1016/j.ajoc.2018.02.028
839:10.1016/j.csbj.2016.10.001
587:McLeod D (February 2005).
1239:10.1007/s00417-008-0966-5
1144:Archives of Ophthalmology
1089:Nika B, Wajda BN (2017).
599:(2). BMJ Group: 229–237.
561:10.1016/j.pop.2015.05.005
48:retinal nerve fiber layer
237:Treatment and management
106:hypertensive retinopathy
737:Survey of Ophthalmology
642:Medical Science Monitor
605:10.1136/bjo.2004.058347
518:. Elsevier: 1012–1025.
476:Schmidt D (June 2008).
248:fluorescent angiography
141:Purtscher's retinopathy
305:Clinical Ophthalmology
173:that is used to treat
135:
110:malignant hypertension
24:
161:A study conducted at
126:
22:
685:Eagle Jr RC (2011).
261:Diabetic retinopathy
149:giant cell arteritis
128:Diabetic retinopathy
40:diabetic retinopathy
654:10.12659/msm.883260
318:10.2147/OPTH.S16272
792:10.1007/BF01204178
648:(8): RA138–RA144.
163:Wills Eye Hospital
136:
62:Signs and symptoms
25:
1102:978-1-4963-5366-5
713:978-0-323-04332-8
533:978-1-4557-0737-9
439:(12): 2407–2414.
203:Chronic migraines
28:Cotton wool spots
1283:
1260:
1259:
1241:
1220:Ulbig M (2008).
1217:
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1167:
1150:(8): 1074–1077.
1138:
1129:
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1114:
1086:
1080:
1079:
1069:
1060:(4): e133–e135.
1045:
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959:
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942:
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52:axonal transport
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185:Possible causes
86:
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75:Pathophysiology
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17:
12:
11:
5:
1289:
1287:
1279:
1278:
1268:
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1212:
1185:(2): 132–133.
1169:
1130:
1101:
1081:
1040:
997:
954:
905:
862:
813:
786:(3): 273–281.
770:
743:(2): 530–543.
727:
712:
692:
677:
628:
574:
555:(3): 451–464.
539:
532:
499:
488:(6): 231–266.
468:
412:
383:(5): 359–394.
342:
271:
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268:
265:
264:
263:
256:
253:
238:
235:
217:
214:
204:
201:
196:antimetabolite
191:
188:
186:
183:
118:acute leukemia
85:
82:
76:
73:
69:microaneurysms
63:
60:
15:
13:
10:
9:
6:
4:
3:
2:
1288:
1277:
1276:Medical signs
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703:Ophthalmology
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433:Ophthalmology
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311:: 1431–1433.
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1232:(11): 1579.
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1057:
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1043:
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878:(1): 69–73.
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736:
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549:Primary Care
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137:
108:, including
94:hypertension
87:
78:
65:
56:
27:
26:
925:: 192–195.
833:: 371–384.
132:hemorrhages
36:funduscopic
1013:: 102661.
970:(1): 4–6.
267:References
190:Cladribine
167:macitentan
1248:0721-832X
1119:cite book
1111:951081880
1035:229283000
900:226988185
765:235809155
722:299238877
216:Diagnosis
1270:Category
1256:29883767
1207:41543770
1076:34921768
1027:33321344
992:10042977
984:26829448
949:29780936
892:33196542
857:27800125
757:34252423
672:22847215
623:15665358
569:26319349
494:18558551
463:19815278
407:21620994
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