Systemic disease and the eye
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Systemic Disease and the Eye. Dr Sancy Low. Background. Patients of all ages and medical history can present with eye problems Symptoms are often associated with systemic disease

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Systemic disease and the eye

Systemic Disease and the Eye

Dr Sancy Low


Background

Background

  • Patients of all ages and medical history can present with eye problems

  • Symptoms are often associated with systemic disease

  • Cardiovascular, endocrine, rheumatoid, connective tissue disease, inherited eye disease and HIV are prominent examples


Topics covered in this lecture

Topics covered in this lecture

  • Diabetic Retinopathy

  • Hypertensive Retinopathy

  • Thyroid Eye Disease

  • Inherited Eye Disease

  • HIV and AIDS


Diabetic retinopathy dr

Diabetic Retinopathy (DR)


Diabetic retinopathy dr1

Diabetic Retinopathy (DR)

  • Microvascular disease of the retinal microcirculation

  • Commonest cause of blindness under 65y

  • Symptom less until loss of vision :

    • Gradual = Central (macula) area of retina involved by oedema, exudates or haemorrhage (maculopathy)

    • Sudden = vitreous haemorrhage from new blood vessels (proliferative DR)


Pathophysiology

Pathophysiology

Hyperglycaemia:

  • Glycosylation of proteins (capillary basement membranes)

  • Loss of endothelial supporting cells (pericytes)

  • Microaneurysms (hallmark of disease) = leakage

  • Capillary closure = ischaemia


Systemic disease and the eye

Type 2 diabetes

Leakage:

Background diabetic retinopathy

Maculopathy

Type 1 diabetes

Ischaemia:

Background diabetic retinopathy

Pre-proliferative diabetic retinopathy

Proliferative

Vitreous haemorhage

Tractional retinal detachment


Background dr

Background DR

Features:

  • Microaneurysms / haemorrhages (‘dots and blots’)

  • Exudates

    Treatment:- Observe


Maculopathy

Maculopathy

Features:

Background DR changes but in the macula area

Treatment:

  • Argon Green laser (induces thermal burn)

  • Either focal or grid laser photocoagulation


Pre proliferative dr

Pre-proliferative DR

Features:

  • Cotton wool spots

  • Extensive haemorrhages

  • Venous beading

  • Intraretinal microvascular abnormalities (IRMA)


Pre proliferative dr1

Pre-proliferative DR

Treatment:

Close observation


Proliferative dr new vessel formation

Proliferative DR: new vessel formation

Treatment:Argon laser panretinal photocoagulation (PRP)


Panretinal photocoagulation

Panretinal photocoagulation

3 days post treatment

Old burns


Laser burns destroy retina in prp

Laser burns: Destroy retina in PRP


End stage disease fibrosis retinal traction and eventual detachment

End Stage Disease: fibrosis, retinal traction and eventual detachment


End stage disease retinal detachment

End Stage Disease: retinal detachment


Summary diabetic retinopathy

Summary: Diabetic Retinopathy


Prevention of dr

Prevention of DR

  • Progressive disease

    • Type I DM: 25% affected by 10y

    • Type II DM: 50% affected by 10y

  • Regular eye tests: Optician, GP, Diabetic team, Ophthalmologists

  • BM control (DCCT)

  • BP control (UKPDS)

  • Stop smoking


Hypertensive retinopathy

Hypertensive retinopathy


Hypertensive retinopathy1

Hypertensive retinopathy

  • Has been graded 1 to 4 (but not satisfactory!)

    • Grade 1: arteriolar narrowing and vein concealment

    • Grade 2: severe arteriolar attenuation and venous deflections at crossings (AV nipping)

    • Grade 3: arteriolar copper wiring, haemorrhages, CWS and hard exudates

    • Grade 4: all of the above plus silver wiring and optic disc swelling


Causes

Causes

  • Systemic hypertension

    • Early signs difficult to tell from ageing changes

  • Malignant hypertension

    • Accelerated severe hypertension causing encephalopathy and papilloedema (sign of raised intracranial pressure)


Mild to moderate chronic hypertensive retinopathy

Mild to moderate chronic hypertensive retinopathy


Arterial and venous changes with some haemorrhages

Arterial and venous changes with some haemorrhages


Severe disease with cotton wool spots ischaemia

Severe disease with cotton wool spots (ischaemia)


Note black areas of non perfusion on ffa fundus fluorescein angiogram

Note black areas of non-perfusion on FFA (fundus fluorescein angiogram)


Malignant hypertension papilloedema ischaemia infarction and macular star

Malignant hypertension - papilloedema, ischaemia, infarction and macular star


Treatment

Treatment

  • Treat the hypertension!

  • Watch out for other complications such as central retinal artery and central retinal vein occlusions (acute visual loss lecture)


Thyroid eye disease

Thyroid Eye Disease


Thyroid eye disease aka grave s ophthalmopathy

Thyroid Eye Disease (aka Grave’s Ophthalmopathy)

  • Associated with thyrotoxicosis (but patient can be clinically and biochemically euthryoid)

  • Organ specific IgG mediated disease

  • Infiltration of muscles and fat surrounding eye

  • Unilateral or bilateral

  • Two stages:

    • Acute inflammatory (risk of sight loss); lasts approx 12-18 months

    • Chronic fibrotic


Examination

Conjunctival chemosis (oedema)

Eyelid retraction (worse on downgaze)

Diplopia (usually upgaze +/- lateral gaze)

Proptosis

Corneal exposure (corneal ulcers if severe)

Compressive optic neuropathy: decreased V/A, RAPD, field loss, reduced colour vision

Examination


Ted symptoms

TED symptoms

  • Nil

  • Grittiness

  • Redness

  • Eyelid swelling

  • Diplopia

  • Cosmetic appearance “bulgy eyes”

  • Visual loss


American thyroid association classification

American Thyroid Association Classification

  • NOSPECS – 6 stages

    • (0) No signs or symptoms

    • (1) Only ocular irritation (dryness, FB)

    • (2) Soft tissue involvement (oedema)

    • (3) Proptosis

    • (4) EOM (extraocular muscle) involvement

    • (5) Corneal involvement

    • (6) Sight loss


Investigation ct orbit proptosis and eom infiltration medial inferior rectus most commonly involved

Investigation: CT orbit Proptosis and EOM infiltration(medial & inferior rectus most commonly involved)


Treatment1

Treatment

  • Manage thyroid dysfunction

  • Ocular lubricants alone (in mild cases)

  • Acute optic nerve compression & corneal exposure

    • Systemic corticosteroids

    • Radiotherapy

    • Surgical orbital decompression

  • Chronic phase

    • Diplopia: Squint surgery, Prisms, Botulinum toxin

    • Cosmetic: Orbital decompression; lid surgery eg blepharoplasty, lid lowering etc


Inherited eye disease e g retinitis pigmentosa

Inherited eye diseasee.g. Retinitis Pigmentosa


Inherited eye disease

Inherited eye disease

  • Genetic eye disease accounts for 20% of blind registration in young adults

  • 40-50% of blindness in children is inherited

  • Retinitis Pigmentosa is the commonest inherited retinal dystrophy

  • Affects 1:5000 of the population

  • It is a heterogeneous condition which primarily affects the retinal rods and later retinal cones


Retinitis pigmentosa

Retinitis Pigmentosa

  • Bone-spicule pigmentation around blood vessels

  • Pale waxy appearance or the peri-papillary retina


Presentation

Presentation

  • RP can be inherited in all forms: AR, XL, AD, and mitochondrial or simplex (where there is no other known family history)

  • Patients usually present with night blindness but can progress to tunnel vision and total blindness (as rods then cones are affected)

  • Syndromic forms of RP exist e.g. Usher syndrome = night blindness and deafness (usually recessive)


Photoreceptor loss

Photoreceptor loss

  • Progressive disease

  • Loss of rods first

  • Cone loss eventually

  • Night blindness first then peripheral field loss, tunnel vision and eventual blindness


Investigations

Investigations

  • Symptoms are usually present before ophthalmoscopic signs

  • Electroretinography (ERG): contact lens probe and measurement of electrical potential of the photoreceptors

  • Visual field analysis

  • Good family history, examine relatives


Treatment research

Treatment/ Research

  • Currently no treatment for RP

  • Low visual aids and blind registration

  • Anti-oxidants (Vitamins A+E have been tried but majority or RP patients not responsive)

  • Genetic mapping and linkage studies

  • E.g. Peripherin gene – current research to find gene therapy


Hiv and aids

HIV and AIDS


Hiv and aids1

HIV and AIDS

  • AIDS is a multisystem disorder of opportunistic infections caused by HIV.

  • Ocular manifestations:

    • Keratitis sicca

    • Common infections: HSV/ HZO/ VZV/ CMV

    • Rarer: Candida choroiditis, Retinal toxoplasmosis

    • Neoplasms: Karposi’s sarcoma, Non-Hodgkin’s lymphoma


Herpes simplex keratitis see red eye lecture

Herpes Simplex Keratitis: see red eye lecture


Herpes zoster ophthalmicus ophthalmic division of trigeminal nerve

Herpes Zoster Ophthalmicus: Ophthalmic division of trigeminal nerve


Cmv retinitis

CMV retinitis

  • Commonest – Occurs in 25% of AIDS patients

  • “Pizza fundus” with overlying vitritis

  • Related to high viral load or low CD4+ count

  • <50 cells/mm3 at greatest risk


Symptoms of cmv retinitis

Symptoms of CMV retinitis

  • May be minimal

  • Floaters and flashing lights

  • Visual field loss

  • Central visual loss (V/A)

  • Signs: progressive necrotising retinitis, retinal haemorrhage and intraretinal necrosis, hazy vitreous


Cmv retinitis treatment

CMV retinitis treatment

  • 14 day induction course: iv ganciclovir or foscarnet

  • May require lifelong treatment

  • 80-100% respond to initial therapy but 50% recur within 3 months

  • May require intravitreal injections or implants


Complications

Complications

  • Related to ocular disease or treatment

  • Blindness from retinal detachment

  • Optic nerve head involvement

  • Ganciclovir causes neutropenia

  • Foscarnet causes renal toxicity

  • Co-existence of other infections (low CD4)


Conclusions

Conclusions


Other systemic diseases

Other systemic diseases

  • Remember dry eyes associated with Rheumatoid Arthritis (Sjogren’s syndrome or keratoconjunctivitis sicca)

  • Remember acute anterior uveitis associated with the seronegative arthritides (50% of patients are HLA-B27 positive and there is an association with ankylosing spondylitis)


Further reading

Further reading

  • There are many other interesting associations of eye disease and general medicine - read up more in good ophthalmology textbooks (see section in the library)

    • Murray, Fielder: Pocket book of Ophthalmology (concise, short notes)

    • Batterbury: Churchill Livinstone colour guide to ophthalmology (good general text)

    • Kanski: Clinical ophthalmology (reference)


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