Post on 06-Feb-2018
Amun Sachdev
Ophthalmology ST1
- Understand which systems may have eye-related
problems
- How the eye problems may herald systemic
disease
- Understand some of the mechanisms of systemic
disease and the eye.
- Systemic diseases affect eyes in various ways
BUT ALSO
- Many of the systemic diseases may be diagnosed first by ophthalmologist
- Endocrine disorders
- Disorders of connective tissues
- Skin diseases
- Gastrointestinal disorders
- Cardiovascular & Pulmonary diseases
- Neurological and muscular disorders
- Most important ones are:
• Diabetes
• Thyroid dysfunction
• Pituitary Tumours
- Visual loss may occur through:
• Diabetic retinopathy
• Cataract
• Glaucoma
• Ischaemic Optic Neuropathy
• Retinal vein and artery occlusions
• IIIrd, IVth and VIth nerve palsies
- Stages: • Background (R1)
• Pre-proliferative (R2)
• Proliferative (R3)
• Maculopathy (M1)
Retinal blot haemorrhages
Microaneurysms
Normal
Venous Loops
On fundoscopy:
- Multiple number of background DR features in all
quadrants
- Particularly features suggesting ischaemia
(e.g. cotton wool spots, venous beading/looping)
Cotton wool spots Venous beading Saccular bulges in vein walls
Normal NVD NVEAlong superior arcade
Vitreous haemorrhage Retinal detachment Rubeosis Iridis
Normal
On fundoscopy:
- Focal / diffuse macular oedema
- Clinically significant macular oedema (CSMO)
o Retinal thickening + Exudates near fovea
- Ischaemic maculopathy
o Loss of capillaries at macula (particularly seen on FFA)
A) Color fundus photograph ; B) FFA Diffuse macular oedema (difficult to visualize on colour photo)
Exudates
Normal
On fundoscopy:
- Focal / diffuse macular oedema
- Clinically significant macular oedema (CSMO)
o Retinal thickening + Exudates near fovea
- Ischaemic maculopathy
o Loss of capillaries at macula (particularly seen on FFA)
Normal capillary bed
Ischaemia
Panretinal Laser PhotocoagulationFresh laser burns
Panretinal Laser PhotocoagulationAtrophic old laser scars
- Blood sugar and BP control are as good as laser treatment for reducing the risk of retinopathy progression and loss of vision
- Headache
- Visual field defect
- Optic nerve dysfunction• Colour deficit
• Visual deterioration
- MRI scan & Neuro referral
Patient may be:
- Euthyroid
- Hypothyroid
- Hyperthyroid • 40% patients with Grave’s disease get eye
signs
• 4-8% will lose vision
Most common cause of proptosis(unilateral or bilateral) in adults
Symptoms / Signs: - Pain on eye movements
- Pain (pressure-like behind the eye)
- Impaired vision
- Impaired eye movements
(diplopia)
- Increasing proptosis
- Red lids
- Red conjunctiva
- Swelling of lids
- Swelling of conjunctiva (chemosis)
- Swelling of caruncle
-Control thyroid status medically-Lubricants-Orbital decompression surgery-Muscle surgery/ prism in glasses-Lid surgery
- Damage to the retina from high blood pressure
- Duration increases risk
- Worse with
- Diabetes
- High cholesterol
- Smoking
- Malignant hypertension
- Grade 1 - No symptoms
- Grade 2 / 3 - Blurred vision / Headache / Diplopia
- Grade 4 - Optic disc swelling → Blurred vision; Field loss
- Often associated with:
- Poor renal function
- Risk of stroke / encephalopathy
Focal closure of retinal microvasculature → Microinfarcts
- Cotton wool spots
- Flame shaped haemorrhages
- Arteriolar narrowing
- Arteriolar colour changes
- AV crossing changes
- Nicking , Flame haemorrhages AV Nicking
‐ Macular star develops in
weeks; resolves in months
‐ Disc oedema develops in
days; resolves in weeks or
months
- Often when BP ~ 250/150 mmHg
- Retinal / Macular oedema
- Macular star in extreme cases
- Disc oedema
- Lower blood pressure to below 140/90mmHg
Second most common vascular disease causing loss of vision
Pathophysiology
- Thrombus formation
- Disease of the vein wall
- External compression of the vein
• Retinal arteries and arterioles and their corresponding veins
share a common adventitial sheath.
• Atherosclerosis and thickening of the arteriole compresses the
vein, eventually causing occlusion.
BRVO CRVO
- Papilloedema
- Flame haemorrhages
- Vein dilation / tortuosity
- Cotton wool spots (esp if ischaemic)
- Advancing age
• Usually age > 65
- Cardiovascular risk factors
• Hypertension (64% cases)
• Hyperlipidaemia
• Diabetes
• Smoking
•Obesity
- Raised intraocular pressure
- Hyperviscosity states - myeloma
- Thrombophilic disorders (considered if age <45)
- Tall stature
- Large eyes
- Myopia
- Ectopia lentis
- Secondary glaucoma
- Retina detachment
- Blue sclera
- Keratoconus
- Ectopia lentis
- Angioid streaks
Episcleritis- Inflammation of episclera (between sclera and
conjunctiva)
- Idiopathic or Autoimmunity
- Symptoms:
- Discomfort/Gritty
- Red
- Watering
- Signs:
- Engorged episcleral vessels
- Translucent white nodule within inflamed area
- Treatment:
- Self-limiting
- Lubricants
- Topical NSAIDs/steroids
Scleritis- Full-thickness inflammation of sclera
- Associated with Rheumatoid Arthritis
- Symptoms:
- Boring pain (wakes patient at night, ↑ on eye movement)
- Red
- Watering
- Photophobia
- ↓ VA
- Treatment:
- Refer to Ophthalmology
- Topical NSAIDs/steroids
- Manage underlying disease
Atopic conditions:Allergic Eye Disease
*Conjunctivitis
*Dry skin around eyes
Acne rosacea:Blepharitis
Chalazion
Stye
Episcleritis
Anterior uveitis
- Crohn’s Disease
- Ulcerative Colitis
- Inflammatory Bowel Disease
- Vitamin A DeficiencyNight Blindness
Retinitis Pigmentosa
- Inflammation of uvea (iris, ciliary body, choroid)- Symptoms:
- Pain
- Red
- Photophobia
- Blurred
- Signs: - Reduced VA
- Raised IOP
- Red conjunctiva
- Cells in anterior chamber
- Irregular pupil (posterior synychiae)
- Pupil reaction sluggish to light
- Treatment: - Refer to Ophthalmology
- Topical steroids
- Cycloplegic (i.e. dilating drops)
Myasthenia Gravis
- Bilateral, Asymmetrical
- Ptosis
- Diplopia
- Fatiguability• Worsens throughout the day
- Positive ice test
- Positive edrophonium test
Multiple Sclerosis & Optic Neuritis
- Inflammation of optic nerve ; Common in young women
- Symptoms - ↓ colour vision
- ↓ visual acuity
- Central scotoma
- Signs- Optic disc swelling
- RAPD
- Management- Usually self-limiting
- Systemic steroids - Speed recovery ; No improvement in outcome