Tag Archives: blind spot

Cotton-Wool Spots

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Anatomy of the globe

What is a cotton-wool spot?

            A cotton-wool spot is the name given to a small white spot in the retina that resembles cotton wool (raw cotton). The retina in your eye is like the film inside a camera. The retina “takes the picture” of objects you look at and sends the message to the brain. The retina is a living tissue, which requires blood supplied by tiny vessels called arteries. If the blood supply to the retina becomes impaired, a small white spot may develop in the inner retina resembling cotton or wool.  This cotton-wool spot is a sign of stressed retina.

What causes a cotton-wool spot?

            There are a wide variety of causes of cotton-wool spots.  Most commonly, they occur along with other changes in the retina from diabetes, high blood pressure, or retinal blood vessel blockage.  However, they may occur due to a great number of other problems including heart diseases, vascular diseases, blood diseases, inflammations, trauma, medications, and infections.  Sometimes, no underlying condition can be identified.  

What are the symptoms of a cotton-wool spot?

            Often cotton-wools spots cause no symptoms at all.  Sometimes they cause a blind spot or dark arc in the vision just off to the side of central vision.  The symptoms come on suddenly and painlessly.  The loss of vision may be temporary or permanent.  Regardless, it usually fades over weeks to months.

What testing is needed?

            Testing depends on the finding on the eye examination.  Sometimes the underlying problem that caused the cotton-wools spots can be determined by the eye exam.  If not, blood tests and scans may be ordered by the ophthalmologist.

What treatment is available?

            Although there is no specific treatment for cotton-wool spots, treatment is directed toward any underlying conditions that caused the cotton-wool spots to appear.  The spots themselves fade away over several months’ time. 

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Retinal photograph showing two cotton-wool spots

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Hydroxychloroquine (Plaquenil) and your eyes

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What side effects can Plaquenil have in the eye?

Although Plaquenil is of proven benefit for a number of medical problems, very rarely it can cause damage to the eyes (1-2% at 10 years and 3-20% at 20 years).  Early symptoms may be subtle.  Small blind spots may develop just above or around the center of vision.  Sometimes they progress to form a doughnut-shaped blind area around the central vision.   If not detected early, the central vision itself may be lost.  When this occurs, color vision is usually affected.  These symptoms, however, are not specific to Plaquenil damage.  The Eye MD must use special tests to determine whether any eye changes are due to Plaquenil or not.  Ocular side effects appear to be dose related, so the risk increases with increased daily dosage.  Individuals less than 5’3” to 5’7” in height regardless of weight should take less than 400mg of Plaquenil per day.  Additionally, a person who weighs less than 135 pounds should take less than 400mg of Plaquenil per day according to current recommendations.  Other factors that may increase the risk of ocular damage include age over 60 years, kidney disease, liver disease, and use of Tamoxifen.

Plaquenil 200mg tablets
Recommended maximum dosage based on height and weight:
Weight (lbs):Height:Maximum dosage:
68-774’0″ – 4’1″One table per day
78-864’2″ – 4’3″One per day except Sunday take two a day
87-964’4″ – 4’5″One per day except M-F take two a day
97-1064’6″ – 4’8″One per day except M-W-F two a day
107-1164’9″ – 4’10”One per day except M-W-F-S two a day
117-1254’11” – 5’0″Two per day except weekend take one a day
126-1345’1″ – 5′ 2″Two per day except Sunday take one a day
≥1355’3″ or tallerTwo per day

*** See updated dosing schedule based on 2017 American Academy of Ophthalmology Guidelines.

What can you do to protect yourself?

Plaquenil is an effective medication with fewer side effects than other medicines used for the same purpose.  However, it is important to monitor your eyes for side effects that might indicate the need to stop taking Plaquenil.  The Amsler grid chart (below) should be checked at least once a week testing each eye separately, using glasses if needed.  Look for a missing part of the grid either above or below the central dot while looking only at the center of the grid.  Additionally, your Eye MD should examine your eyes every year with specific testing to look for early signs of retinal changes.

Blue Yellow Amsler Grid
While focusing on center of grid, make sure the whole grid is seen…no missing areas (click on image to enlarge)

What happens if you develop retinal changes from Plaquenil?

Retinal damage from Plaquenil is extremely rare. If early retinal changes are found, Plaquenil may be discontinued.  By discontinuing Plaquenil at an early stage, vision can be saved.  Continued examination is important to monitor the eyes for further changes.

By Scott E. Pautler, MD

Reference: Article on early detection

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

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