ocular manifestations of systemic diseases
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Ocular Manifestations of Systemic Diseases. Dalman. Dysthyroid Orbitopathy. autoimmune disorder usually associated with Graves\' disease 10-25% euthyroid extra-ocular muscles are the target of the autoimmune attack  restrictive ophthalmoplegia and proptosis Cardinal Signs

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dysthyroid orbitopathy
  • autoimmune disorder usually associated with Graves\' disease
  • 10-25% euthyroid
  • extra-ocular muscles are the target of the autoimmune attack  restrictive ophthalmoplegia and proptosis
  • Cardinal Signs
    • upper eyelid retraction and lag, conjunctival injection and chemosis, and periorbital edema.
dysthyroid orbitopathy1
  • Pathophysiology
    • antibody-mediated reaction against the TSH receptor with orbital fibroblast modulation of T-cell lymphocytes
dysthyroid orbitopathy2
  • Pathophysiology

T- cells


Thyroid cells

Hyperosmotic shift

Orbital fibroblast

EOM edema



dysthyroid orbitopathy3
  • Pathophysiology

Preadipocyte fibroblasts


Inc. orbital volume

Inc. fat




Tissue damage and fibrosis

EO motility restriction

dysthyroid orbitopathy7
  • Management
    • self-limited (over 1 year)
    • No immediate cure available
dysthyroid orbitopathy8
  • Management
    • Orbital radiation
      • moderate-to-severe inflammatory symptoms, diplopia, and visual loss in patients with TAO
    • Optic nerve compression
      • High-dose steroids (proceed to surgery if unresponsive)
    • Surgical
      • Orbital decompression
      • Strabismus surgery
      • Lid lengthening
      • Blepharoplasty
occular changes in hypertension
Occular Changes in Hypertension
  • Damage to the retina caused by high blood pressure
  • 3 manifestations
    • Hypertensive retinopathy
    • Hypertensive optic neuropathy
    • Hypertensive choroidopathy
occular changes in hypertension1
Occular Changes in Hypertension
  • Pathophysiology
    • Retinal microvasculature

Inc BP

Hyperoxic & hypercapneic stress

Bifurcation angles and retinal arteriolar diameters show Dec vascular reactivity

Disadvantageous branching geometry in retinal vasculature

occular changes in hypertension2
Occular Changes in Hypertension
  • Pathophysiology
    • Dynamics of ocular blood flow

Hypertensive arterial changes

Inc resistance to optic nerve head blood flow

Inc BP

Breakdown of autoregulation

occular changes in hypertension3
Occular Changes in Hypertension
  • Pathophysiology
    • Different manifestations because
      • Acute HTN disrupts blood-retinal barriers
      • Retinal and optic nerve head vascular beds have autoregulation (choroidal has none)
      • Choroidal vessels has no blood-ocular barrier
      • Retinal vessels (no autonomic nerve supply)
      • Choroidal vessels (richly supplied by both sympathetic and parasympathetic nerves)
hypertensive retinopathy
Hypertensive Retinopathy
  • Represents target-organ damage
hypertensive retinopathy1
Hypertensive Retinopathy
  • Clinical features
    • Vasoconstriction
    • Fundus
      • focal and generalised arteriolar narrowing, microaneurysms, intraretinal hemorrhages, cotton-wool spots, hard exudates, optic disc swelling
      • 2o to arteriolosclerosis  arteriovenous nipping
      • Flame-shaped hemorrhages (abnormal vascular permeability)
      • Macular star (lipid deposition around the fovea)
      • Disc swelling (minimal microvascular change)
hypertensive retinopathy2
Hypertensive Retinopathy
  • Clinical features
    • Vasoconstriction
    • Fundus
      • Untreated hypertension  hemorrhagic detachment of retina and vitreous hemorrhage
hypertensive retinopathy3
Hypertensive Retinopathy
  • Clinical features
    • Vasoconstriction
    • Fundus
    • Secondary arteriosclerosis
      • Bonnet’s sign - banking of the venule distal to the crossing
      • Gunn’s sign - nipping of the blood column
      • Salus’ sign - displacement of the venule at right angles to the arteriole
hypertensive retinopathy4
Hypertensive Retinopathy
  • Gunn’s sign and Bonnet’s sign
hypertensive retinopathy5
Hypertensive Retinopathy
  • Focal arterial narrowing of the retina
hypertensive optic neuropathy
Hypertensive Optic Neuropathy
  • Papilloedema or bilateral disc swelling
    • Grade IV hypertensive retinopathy
    • Poor prognostic sign
    • Other causes like space-occupying lesions and benign intracranial HTN should be excluded
    • Theories on the pathophysiology
      • Ischemia and raised ICP as a part of hypertensive retinopathy/enchephalopathy
hypertensive optic neuropathy1
Hypertensive Optic Neuropathy
  • Usually resolve following control of BP, but some might develop disc pallor
  • Longstanding uncontrolled HTN  retinal nerve fiber loss
hypertensive choroidopathy
Hypertensive Choroidopathy
  • Less well recognized than retinopathy
  • Commonly described features:
    • Choroidal vascular sclerosis
    • Elschnig spots – focal areas of degenerative retinal pigment epithelium
    • Siegrist’s streaks – linear pigment epithelial changes
      • poor prognosis
  • Control hypertension
  • Grade I and II
    • Non-urgent referral
  • Grade III
    • More urgent referral to the GP
  • Grade IV
    • Patient is in medical crisis. Patient needs immediate referral to a hospital eye casualty department