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Fundoscopic Findings in Fundoscopic Findings in Common Systemic Common Systemic
DiseasesDiseases
Jocelyn Kuryan, MDJocelyn Kuryan, MD
Chief ResidentChief ResidentDepartment of OphthalmologyDepartment of Ophthalmology
Albert Einstein College of MedicineAlbert Einstein College of MedicineMontefiore Medical Center/Jacobi Medical CenterMontefiore Medical Center/Jacobi Medical Center
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OutlineOutline Retinal findings:Retinal findings:
Diabetes MellitusDiabetes Mellitus HypertensionHypertension HIV/AIDSHIV/AIDS
Overview of Some Common Eye Diseases:Overview of Some Common Eye Diseases: GlaucomaGlaucoma Macular DegenerationMacular Degeneration CataractCataract
Screening Recommendations for AdultsScreening Recommendations for Adults
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Normal RetinaNormal Retina
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Diabetic RetinopathyDiabetic Retinopathy Leading cause of new cases Leading cause of new cases
of legal blindness among of legal blindness among working-age Americans working-age Americans
Duration of DM is a major Duration of DM is a major risk factor for the risk factor for the development of retinopathy development of retinopathy
The severity of The severity of hyperglycemia is the key hyperglycemia is the key alterable risk factoralterable risk factor
Intensive management of Intensive management of HTN has been show to slow HTN has been show to slow DR progressionDR progression
DuratioDuration (yrs)n (yrs)
% Type I % Type I with DRwith DR
% Type II % Type II with DRwith DR
Up to 5Up to 5 2525 40 (on insulin)40 (on insulin)
24 (no insulin)24 (no insulin)
> 15 > 15 8080 84 (on insulin)84 (on insulin)
53 (no insulin)53 (no insulin)
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Natural History of Natural History of Diabetic RetinopathyDiabetic Retinopathy
Early stages (NPDR=non proliferative DR) Early stages (NPDR=non proliferative DR) retinal vascular abnormalities increased retinal retinal vascular abnormalities increased retinal
vascular permeability can lead to macular vascular permeability can lead to macular edemaedema
Gradual closure of retinal vessels, Gradual closure of retinal vessels, impaired perfusion & retinal ischemia impaired perfusion & retinal ischemia
Proliferative disease (PDR)Proliferative disease (PDR) onset of neovascularization induced by retinal onset of neovascularization induced by retinal
ischemiaischemia new vessels can undergo fibrosis & contractionnew vessels can undergo fibrosis & contraction
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Severity of Diabetic Severity of Diabetic RetinopathyRetinopathy
International Clinical Diabetic Retinopathy Severity ScaleInternational Clinical Diabetic Retinopathy Severity Scale
Proposed Disease Proposed Disease Severity LevelSeverity Level
Findings Observable upon DFEFindings Observable upon DFE
No apparent retinopathyNo apparent retinopathy No abnormalitiesNo abnormalities
Mild NPDRMild NPDR Microaneurysms onlyMicroaneurysms only
Moderate NPDRModerate NPDR More than just MAs but less severe More than just MAs but less severe than severe NPDRthan severe NPDR
Severe NPDRSevere NPDR Any one of the following:Any one of the following: 20 intraretinal hemorrhages in 20 intraretinal hemorrhages in
each of 4 quadrantseach of 4 quadrants definite venous beading in ≥ 2 definite venous beading in ≥ 2
quadrantsquadrants prominent IRMA in ≥ 1 quadrantsprominent IRMA in ≥ 1 quadrants
PDRPDR One or both of the following:One or both of the following: NeovascularizationNeovascularization Vitreous/Preretinal hemorrhageVitreous/Preretinal hemorrhage
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Recommended Eye Examination Recommended Eye Examination Schedule for Patients with Diabetes Schedule for Patients with Diabetes
MellitusMellitus
Diabetes Diabetes TypeType
Recommended Recommended Time Time of 1of 1stst
ExaminationExamination
Recommended Follow-upRecommended Follow-up
Type 1Type 1 5 yrs after onset5 yrs after onset YearlyYearly
Type 2Type 2 At time of At time of diagnosisdiagnosis
YearlyYearly
Prior to Prior to pregnancy pregnancy (type 1 or (type 1 or 2)2)
Prior to conception Prior to conception or early in 1or early in 1stst trimestertrimester
No retinopathy to mild/mod NPDR: No retinopathy to mild/mod NPDR: every 3-12 months every 3-12 months Severe NPDR or worse: every 1-3 Severe NPDR or worse: every 1-3 monthsmonths
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Nonproliferative Diabetic Nonproliferative Diabetic RetinopathyRetinopathy
http://depts.washington.edu/ophthweb/images/J02diabetic.jpg
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Proliferative Diabetic Proliferative Diabetic RetinopathyRetinopathy
http://blog.visivite.com/wp-content/uploads/2009/08/proliferative-diabetic-retinopathy.jpg
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Fibrovascular ProliferationFibrovascular Proliferation
http://emedicine.medscape.com/article/1225210-media
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Tractional Retinal Tractional Retinal DetachmentDetachment
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Fluorescein Angiogram Fluorescein Angiogram showing Neovascularizationshowing Neovascularization
http://emedicine.medscape.com/article/1225210-media
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Treatment OptionsTreatment Options Severe NPDR with evidence of areas of retinal Severe NPDR with evidence of areas of retinal
nonperfusion – panretinal photocoagulation (PRP)nonperfusion – panretinal photocoagulation (PRP) Goal: lower levels of VEGF which is thought to promote Goal: lower levels of VEGF which is thought to promote
and propagate neovascularizationand propagate neovascularization PDR - panretinal photocoagulationPDR - panretinal photocoagulation Clinically Significant Macular Edema – focal laser Clinically Significant Macular Edema – focal laser
photocoagulation directly to leaking photocoagulation directly to leaking microaneurysms (as seen on fluorescein microaneurysms (as seen on fluorescein angiogram) angiogram)
Vitreous Hemorrhage and/or Tractional Retinal Vitreous Hemorrhage and/or Tractional Retinal Detachment – VitrectomyDetachment – Vitrectomy
Anti-VEGF intravitreal injections (i.e. Lucentis, Anti-VEGF intravitreal injections (i.e. Lucentis, Avastin) initially used for macular degeneration are Avastin) initially used for macular degeneration are increasingly being used to treat neovascularization increasingly being used to treat neovascularization associated with DRassociated with DR
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Panretinal PhotocoagulationPanretinal Photocoagulation
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Hypertensive RetinopathyHypertensive Retinopathy Increased incidence in patients with uncontrolled Increased incidence in patients with uncontrolled
hypertensionhypertension44
Associated with increased risk for cardiovascular disease Associated with increased risk for cardiovascular disease and strokeand stroke77
Some studies have linked renal dysfunction with retinal Some studies have linked renal dysfunction with retinal vascular changesvascular changes66
HTN risk factor for retinal vascular occlusions, macular HTN risk factor for retinal vascular occlusions, macular degeneration, ischemic optic neuropathydegeneration, ischemic optic neuropathy55
Classification (modified Scheie classification): Classification (modified Scheie classification): Grade 0 - No changes Grade 0 - No changes Grade 1 - Barely detectable arterial narrowing Grade 1 - Barely detectable arterial narrowing Grade 2 - Obvious arterial narrowing with focal irregularities Grade 2 - Obvious arterial narrowing with focal irregularities Grade 3 - Grade 2 plus retinal hemorrhages and/or exudates Grade 3 - Grade 2 plus retinal hemorrhages and/or exudates Grade 4 - Grade 3 plus disc swellingGrade 4 - Grade 3 plus disc swelling
Treatment – BP controlTreatment – BP control
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Arteriolar Narrowing & Arteriolar Narrowing & SclerosisSclerosis
http://usa.nidek.com/wp-content/uploads/2008/10/6.jpg
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A-V nickingA-V nicking
http://eyephoto.ophth.wisc.edu/LightBoxImages/A8.jpg
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Retinal Hemorrhages, CWSRetinal Hemorrhages, CWS
http://www.otm1.com/page/services_otm
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Grosso A et al. Br J Ophthalmol 2005;89:1646-1654©2005 by BMJ Publishing Group Ltd.
Malignant Hypertensive Malignant Hypertensive RetinopathyRetinopathy
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Disc Edema & Malignant Disc Edema & Malignant HypertensionHypertension
http://www.opt.indiana.edu/ce/retvasdz/graphics/img030.jpg
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HIV RetinopathyHIV Retinopathy
DefinitionDefinition: noninfectious microvascular disorder : noninfectious microvascular disorder characterised by cotton-wool spots (CWS), characterised by cotton-wool spots (CWS), microaneurysms, retinal hemorrhages, microaneurysms, retinal hemorrhages, telangiectatic vascular changes, and areas of telangiectatic vascular changes, and areas of capillary nonperfusioncapillary nonperfusion99
CWS in 25 to 50% of patients and are the earliest CWS in 25 to 50% of patients and are the earliest and most consistent finding; mimic diabetic & and most consistent finding; mimic diabetic & hypertensive retinopathyhypertensive retinopathy
More prevalent in the pre-HAART eraMore prevalent in the pre-HAART era1010
Ocular lesions in AIDS are varied and affect Ocular lesions in AIDS are varied and affect almost all structures of the eye & occur in 40 to almost all structures of the eye & occur in 40 to 70% of AIDS patients70% of AIDS patients88
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HIV RetinopathyHIV Retinopathy
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CMV RetinitisCMV Retinitis
It usually occurs when the CD4 cell count is less It usually occurs when the CD4 cell count is less than 100 cells/mmthan 100 cells/mm3 113 11
Leads to viral invasion of retinal cells and retinal Leads to viral invasion of retinal cells and retinal necrosis necrosis
““Pizza pie retinopathy” scattered yellow-white Pizza pie retinopathy” scattered yellow-white areas of necrotizing retinitis with variable degree areas of necrotizing retinitis with variable degree of hemorrhage and mild vitreous inflammation of hemorrhage and mild vitreous inflammation
Can result in retinal detachmentCan result in retinal detachment Treatment: systemic and/or local Treatment: systemic and/or local
IV and oral ganciclovir, IV foscarnet, IV cidofovir, the IV and oral ganciclovir, IV foscarnet, IV cidofovir, the ganciclovir implant and fomivirsen ganciclovir implant and fomivirsen
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““Pizza Pie”Pizza Pie”
http://upload.wikimedia.org/wikipedia/commons/9/90/Fundus_photograph-CMV_retinitis_EDA07.JPG
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CMV retinitisCMV retinitis
Early necrosis at periphery
http://emedicine.medscape.com/article/1227228-media
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Progressive Outer Retinal Progressive Outer Retinal Necrosis (PORN)Necrosis (PORN)
Caused by Herpes simplex virus (HSV) or Varicella Caused by Herpes simplex virus (HSV) or Varicella zosterzoster
Can present with anterior uveitis, blurred vision Can present with anterior uveitis, blurred vision and severe eye painand severe eye pain
Peripheral retinitis progresses centrally. Peripheral retinitis progresses centrally. Regresses over 2-3 weeks & can cause retinal Regresses over 2-3 weeks & can cause retinal traction & tears leading to retinal detachmenttraction & tears leading to retinal detachment
Treatment: IV and PO acyclovirTreatment: IV and PO acyclovir Can result in retinal detachmentCan result in retinal detachment Prophylactic laser photocoagulation is considered Prophylactic laser photocoagulation is considered
beneficial following resolution of retinitis.beneficial following resolution of retinitis.
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Outer Retinal NecrosisOuter Retinal Necrosis
Cream-colored areas of retinal necrosis with atrophic holes
http://www.retinalphysician.com/archive%5C2008%5CNovember%5Cimages/RP_November_A04_Fig02.jpg
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Other Common Other Common Ophthalmologic DiagnosesOphthalmologic Diagnoses
GlaucomaGlaucoma Macular DegenerationMacular Degeneration CataractCataract
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GlaucomaGlaucoma
Main types: primary open angle glaucoma, Main types: primary open angle glaucoma, angle closure glaucoma (ACG)angle closure glaucoma (ACG) POAG – chronic progressive optic neuropathy that POAG – chronic progressive optic neuropathy that
leads to peripheral vision loss and blindnessleads to peripheral vision loss and blindness Treatment – IOP lowering drops, close monitoring of Treatment – IOP lowering drops, close monitoring of
visual fields; surgery in those who fail medical visual fields; surgery in those who fail medical managementmanagement
Often runs in families; higher prevalence among BlacksOften runs in families; higher prevalence among Blacks1212
ACG – acute closure of aqueous drainage ACG – acute closure of aqueous drainage channels that leads to elevated eye pressure, channels that leads to elevated eye pressure, pain, nausea, vomiting and vision losspain, nausea, vomiting and vision loss
Treatment – IOP lowering drops, peripheral iridectomyTreatment – IOP lowering drops, peripheral iridectomy
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Optic NerveOptic Nerve
Normal Glaucoma
http://www.besteyesurgery.co.uk/images/glaucoma/glaucoma_optic_nerve.jpg
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Humphrey Visual FieldHumphrey Visual Field
Normal
Advanced Glaucoma with Sparing of Central Vision
Superior Visual Field Deficit
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Age Related Macular Age Related Macular DegenerationDegeneration22
A leading cause of severe, irreversible vision A leading cause of severe, irreversible vision impairment in developed countries impairment in developed countries
The prevalence, incidence, and progression of The prevalence, incidence, and progression of AMD increase with age AMD increase with age
Late stages of AMD are more common among Late stages of AMD are more common among whites than blackswhites than blacks
Smoking doubles the risk of AMD Smoking doubles the risk of AMD Additional risk factors may include low levels of Additional risk factors may include low levels of
antioxidants, which led to the development of antioxidants, which led to the development of AREDS vitaminsAREDS vitamins beneficial effect of high doses of antioxidant beneficial effect of high doses of antioxidant
vitamins (vitamins C, E, beta-carotene) and zinc vitamins (vitamins C, E, beta-carotene) and zinc supplementation in reducing progressionsupplementation in reducing progression
““Dry” = drusen and “Wet” = neovascularizationDry” = drusen and “Wet” = neovascularization Screening – abnormalities on Amsler gridScreening – abnormalities on Amsler grid Treatment – anti-VEGF intravitreal injections, Treatment – anti-VEGF intravitreal injections,
photodynamic therapy, laser photocoagulationphotodynamic therapy, laser photocoagulation
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Amsler GridAmsler Grid
Normal Scotoma & Metamorphopsia
http://www.vrmny.com/images/amsler_lg.jpg
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Dry AMDDry AMD
http://www.blackwelleyesight.com/wp-content/uploads/2008/05/mac-deg-1.jpg
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Wet AMDWet AMD
http://www.clevelandsightcenter.org/resources/conditions/images/wet_macular_fundus.jpg
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CataractCataract33
A cataract is a degradation of the optical quality A cataract is a degradation of the optical quality of the crystalline lens. of the crystalline lens.
Cataracts are the leading cause of blindness Cataracts are the leading cause of blindness worldwide worldwide
Early development and/or more rapid progression Early development and/or more rapid progression in diabetics and with corticosteroid usein diabetics and with corticosteroid use
Indications for SurgeryIndications for Surgery Primary: visual function that no longer meets the Primary: visual function that no longer meets the
patient’s needs and for which cataract surgery provides patient’s needs and for which cataract surgery provides a reasonable likelihood of improved visiona reasonable likelihood of improved vision
Secondary: anisometropia, interference with optimal Secondary: anisometropia, interference with optimal diagnosis or management of posterior segment diagnosis or management of posterior segment conditions, causing inflammation, inducing angle closureconditions, causing inflammation, inducing angle closure
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CataractCataract
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Screening Recommendations Screening Recommendations for Adultsfor Adults1414
Age 20-29: a complete eye exam at least once Age 20-29: a complete eye exam at least once Age 30-39: a complete eye exam at least twiceAge 30-39: a complete eye exam at least twice Age 40-64: baseline exam at 40, then follow-up Age 40-64: baseline exam at 40, then follow-up
as per ophthalmologist as per ophthalmologist Age > 65: every 1-2 yearsAge > 65: every 1-2 years Patients with risk factors for eye disease – family Patients with risk factors for eye disease – family
history, history of eye injury, diabetes, history, history of eye injury, diabetes, hypertension, etc. should be seen regularlyhypertension, etc. should be seen regularly
Patients with symptoms – i.e. flashes, floaters, Patients with symptoms – i.e. flashes, floaters, visual changes or distorted vision, etc. should be visual changes or distorted vision, etc. should be seen as soon as possibleseen as soon as possible
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QUESTIONS?QUESTIONS?
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REFERENCESREFERENCES
1.1. American Academy of Ophthalmology Preferred Practice Patterns – Diabetic RetinopathyAmerican Academy of Ophthalmology Preferred Practice Patterns – Diabetic Retinopathy2.2. American Academy of Ophthalmology Preferred Practice Patterns – Age Related Macular DegenerationAmerican Academy of Ophthalmology Preferred Practice Patterns – Age Related Macular Degeneration3.3. American Academy of Ophthalmology Preferred Practice Patterns – Cataract in the Adult EyeAmerican Academy of Ophthalmology Preferred Practice Patterns – Cataract in the Adult Eye4.4. R Klein, B E Klein, and S E Moss. The relation of systemic hypertension to changes in the retinal vasculature: the R Klein, B E Klein, and S E Moss. The relation of systemic hypertension to changes in the retinal vasculature: the
Beaver Dam Eye Study. Trans Am Ophthalmol Soc. 1997; 95: 329–350.Beaver Dam Eye Study. Trans Am Ophthalmol Soc. 1997; 95: 329–350.5.5. Grosso A, Veglio F, Porta M, Grignolo FM, Wong TY. Hypertensive retinopathy revisited: some answers, more Grosso A, Veglio F, Porta M, Grignolo FM, Wong TY. Hypertensive retinopathy revisited: some answers, more
questions. Br J Ophthalmol. 2005 Dec;89(12):1646-54.questions. Br J Ophthalmol. 2005 Dec;89(12):1646-54.6.6. Wong TY, Coresh J, Klein R, et al. Retinal microvascular abnormalities and renal dysfunction: the Atherosclerosis Risk Wong TY, Coresh J, Klein R, et al. Retinal microvascular abnormalities and renal dysfunction: the Atherosclerosis Risk
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