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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 orbitopathy4

Dysthyroid orbitopathy5

Dysthyroid orbitopathy6

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

Hypertensive choroidopathy1
Hypertensive Choroidopathy

  • Elschnig spots


  • 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