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